Patient Safety Tool: Adverse Event Reporting Form for Office-Based Surgery

The New York State Department of Health offers a free, downloadable adverse event reporting form for office-based surgery.

The four-page form includes sections detailing accreditation, the nature of the adverse events, quality improvement efforts, sedation/anesthesia and medication administration.

Download the adverse event reporting form (PDF) for use and adaptation in your facility.

Note: View our database providing 150 reports that link to free, downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.

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