Equipment Event
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Equipment Event
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Section 1: Initiator Details
Initiator name
*
Initiator's email
Initiator department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Date of occurrence
*
Time of occurrence
*
Other Initiator Department
*
Location of occurrence
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Other
*
Room #
Additional details
Section 2: Occurrence Details
Name of Equipment
*
Serial Number
Event/Incident Reason
*
Failed
Not Available
Broken
Improper set-up
Wrong equipment
Expired
Not turning ON
Other
Other Event/Incident Reason
*
Patient Harmed
Yes
No
Patient Name
*
DOB
FIN number
Equipment Sequestered / Isolated
Yes
No
Date
*
Description of event
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