Complete the patient harm questionnaire

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We will never share your personal information or without your permission.

Your last name *

Your first name *

Your phone number *

Your email address *

Patient last name *

Patient first name *

Patient phone number *

Patient email address *

Patient city or town *

Patient state *

Your relationship to patient *

Patient age at time of incident *

Patient's insurance at the time of incident *

Name of health care facility *

City where facility is located *

State where facility is located *

Type of facility *

Admission date [mm/dd/yyyy] *

Reason for admission *

If an elective admission; what was the purpose of the admission? *

Type of admission *

If "other; " please explain

Type of harm *

(check all that apply)

Infection

Surgical injury

Bedsore(s)

Fall(s)

Medication

Blood clot

Device: orthopedic

Device: heart

Other:

Required

If infection; what type of an infection

If other; what type of infection?

Please explain what happened *

What was the outcome? *

Please explain the outcome in your words

How did the harm affect the patient's life?

How did the harm affect the patient's family?

Who was at fault? *

(check all that apply)

Doctor

Nurse

Aide

Dentist

Management

Faulty device

Insurance company

Unknown

Other:

Required

Did the medical facility acknowledge the harm? *

Was this a case of unnecessary treatment or over-treatment? *

Did the medical providers responsible acknowledge the harm? *

Did the patient and/or the patient's family receive an apology? *

Yes

Do you think an apology was necessary? *

Yes

Was the patient; or the patient's insurance payer; billed for the harm? If so; how much?

Did the insurance pay the bill? *

Yes

Partially paid

Unknown

Other:

Did the insurance payer take any action to protect the patient or future patients? *

Yes

Unknown

If "yes; " what action was taken? *

How much was the patient; or the patient's family; billed for the harm?

How much did the patient or patient's family pay?

Did the incident cause any long-term financial problems; such as bankruptcy or debt? If so; please explain in your own words.

Did anyone file a complaint with an oversight agency? If so; please select the agencies or organizations that received complaints. *

(check all that apply)

No complaint was filed

Medical board

Nursing board

State licensing agency

Medicare/Medicaid

Joint Commission or other accrediting agency

Medicare Quality Improvement Organization

Unknown

Other:

Required

What was the response to the complaint by oversight agencies? *

Did the medical facility suffer any consequences for the harm it caused the patient? *

Yes

Unknown

Did the medical provider - doctor; nurse; etc. - suffer any consequences? *

Yes

Unknown

If you answered "yes" to either of the above two questions; what were the consequences?

Do you have the patient's medical records? *

Yes

Do the medical records document the harm? *

Yes

Unknown

Were the medical records altered in any way? *

Yes

Unknown

Did the patient or patient's family sue the medical facility or provider? *

Yes

If so; what was the outcome of the lawsuit? *

If "other; " on the question above - what happened?

Was there a gag order to keep the patient from talking about the incident? *

If "other" to the above question; please explain

Would you be willing to talk to a reporter? *

Yes

Do you mind if we share your information with academic researchers interested in patient harm? *

No information that identifies you would be included in any academic research.

Yes

Is there anything else you would like us to know?

Submit

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