The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

fNydzeMFjJpUvXBHoR3QJhM4fae4XArRHZ8KIEbNWQGbRpBqIkpg3z2cGPX4BB99y4kRVRBhB8Wptx5qQUB2y23tLXjayyIPRUKqASyk2caXg6xi9

Patient Safety Event Reporting Form

Please report all patient safety events, even those that don't reach the patient. This allows National Jewish Health to identify, analyze and learn from the sequence of events that may potentially lead to errors before they affect patients. Reported events include:

Potential Events: Unsafe conditions that increase the likelihood of a patient safety event.
Near Misses: Events that are caught and do not reach the patient.
Actual Events: Patient safety events that reach the patient and may or may not cause harm.

Report Date

M-D-Y

Patient/Visitor First Name

Patient/Visitor Last Name

Medical Record Number (MRN)

DOB

M-D-Y

Event Date

* must provide value

M-D-Y

Event Time

* must provide value

Please provide your NJH email address (start typing and your email will populate)
IF YOUR NJH EMAIL DOES NOT APPEAR IN THE ABOVE LIST Enter "N/A" and complete the open text question prompt with your NJH Email.

* must provide value

Please type your NJH Email address in the following format: "smithj@njhealth.org"

* must provide value

Name of Reporting Staff (Optional)

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.