Complete the patient harm questionnaire
We will never share your personal information or without your permission.
Your last name *
Your answer
Your first name *
Your answer
Your phone number *
Your answer
Your email address *
Your answer
Patient last name *
Your answer
Patient first name *
Your answer
Patient phone number *
Your answer
Patient email address *
Your answer
Patient city or town *
Your answer
Patient state *
Your answer
Your relationship to patient *
Patient age at time of incident *
Your answer
Patient's insurance at the time of incident *
Name of health care facility *
Your answer
City where facility is located *
Your answer
State where facility is located *
Your answer
Type of facility *
Admission date [mm/dd/yyyy] *
Your answer
Reason for admission *
Your answer
If an elective admission; what was the purpose of the admission? *
Type of admission *
If "other; " please explain
Your answer
Type of harm *
(check all that apply)
Required
If infection; what type of an infection
If other; what type of infection?
Your answer
Please explain what happened *
Your answer
What was the outcome? *
Please explain the outcome in your words
Your answer
How did the harm affect the patient's life?
Your answer
How did the harm affect the patient's family?
Your answer
Who was at fault? *
(check all that apply)
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? *
Do you think an apology was necessary? *
Was the patient; or the patient's insurance payer; billed for the harm? If so; how much?
Your answer
Did the insurance pay the bill? *
Did the insurance payer take any action to protect the patient or future patients? *
If "yes; " what action was taken? *
Your answer
How much was the patient; or the patient's family; billed for the harm?
Your answer
How much did the patient or patient's family pay?
Your answer
Did the incident cause any long-term financial problems; such as bankruptcy or debt? If so; please explain in your own words.
Your answer
Did anyone file a complaint with an oversight agency? If so; please select the agencies or organizations that received complaints. *
(check all that apply)
Required
What was the response to the complaint by oversight agencies? *
Your answer
Did the medical facility suffer any consequences for the harm it caused the patient? *
Did the medical provider - doctor; nurse; etc. - suffer any consequences? *
If you answered "yes" to either of the above two questions; what were the consequences?
Your answer
Do you have the patient's medical records? *
Do the medical records document the harm? *
Were the medical records altered in any way? *
Did the patient or patient's family sue the medical facility or provider? *
If so; what was the outcome of the lawsuit? *
If "other; " on the question above - what happened?
Your answer
Was there a gag order to keep the patient from talking about the incident? *
If "other" to the above question; please explain
Your answer
Would you be willing to talk to a reporter? *
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.
Is there anything else you would like us to know?
Your answer
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