Describe
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Describe
Classify
Reflect
Patient
Male
Female
No Patient Involved
Multiple People Involved
Age
...
Less than 28 days
Less than 1 year
1 to 17 years
18 to 34 years
35 to 49 years
50 to 64 years
65 to 79 years
80 years or older
Habitus
...
Underweight (BMI < 18.5)
Normal (BMI 18.5 - 25)
Overweight (BMI > 25)
Obese (BMI > 30)
Morbidly Obese (BMI > 40)
ASA Status
...
I
I E
II
II E
III
III E
IV
IV E
V
V E
VI
Area
...
OR
Procedure Center
OB
Ambulatory Surgery Center
Preop Clinic
Preop Holding
PACU
Postop Ward
ICU
Out of Hospital
Other
Unknown
VI
Time
...
Day (6AM-4PM)
Evening (4PM-10PM)
Night (10PM-6AM)
Staffing
Immediate Provider
-- None --
Anesthesiologist
Anesthesia Fellow
Anesthesia Resident
CRNA
Anesthesia Assistant
PA
OR Nurse
Other
Supervising Provider
-- None --
Anesthesiologist
Anesthesia Fellow
Anesthesia Resident
CRNA
Anesthesia Assistant
PA
OR Nurse
Other
Other Provider
-- None --
Anesthesiologist
Anesthesia Fellow
Anesthesia Resident
CRNA
Anesthesia Assistant
PA
OR Nurse
Other
Procedural
...
General Surgery
Cardiothoracic Surgery
Vascular Surgery
Orthopedic Surgery
OHNS
OMFS
Plastics
ENT
Description
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Classify
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Event Classification
Category
Airway Management
Anesthetic/Operative Complications
Blood
Cardiac
Documentation
Equipment
Immunological
Meds
Neuro
Pulmonary/Resp
Regional Anesthesia
Renal
Vascular Complications
Other
Subcategory
Airway fire
Aspiration
Cannot intubate
Cannot ventilate
Dental injury
Difficult intubation
Difficult ventilation
Difficulty/failed LMA placement
Emergency trach placed
Epistaxis
Esophageal intubation
Extubation
Laryngospasm - treated with:
Post extubation stridor
Soft tissue injury
Sub-glottic stenosis
Other
Type
Expected
Unexpected
Other
Severity Classification
Unsafe Condition - Any circumstance that increases the probability of a patient safety event.
Near Miss - Event occurred but did not reach patient.
No Harm - Reached patient, but no harm was evident.
Emotional Distress or Inconvenience - Mild and transient anxiety, pain, or physical discomfort.
Additional Treatment - Injury limited to additional intervention during admission but no other injury.
Temporary Harm - Bodily or psychological injury, but likely not permanent.
Permanent Harm - Lifelong bodily or psychological injury or increased susceptibility to disease.
Severe Permanent Harm - Severe lifelong bodily or psychological injury or disfigurement.
Death - Death at the time of the assessment.
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Reflect
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Describe
Classify
Reflect
Reflection
Do you think this incident was preventable?
No
Yes
In responding to this event, did the team use any emergency manual?
(a.k.a cognitive aid, checklist)
No
Yes
Contributing Factors (Optional)
Lessons Learned (Optional)
Submit to AIRS
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