Medical Division
EMS Problem Report
Please select any that apply to the situation you are reporting:
Medication
Equipment failures/malfunctions
Patient hand off with ER staff
Other
Station
*
Your Name
*
Medication Issues
Name of Medication
Type of error (Select all that apply):
Dose
Route
Indications
Contraindications
Other
What happened?
What contributed to the error?
Was the patient informed?
Yes
No
Was the receiving Hospital informed?
Yes
No
Any thoughts on system-level changes to prevent future occurrences?
Equipment Failure/Malfunctions
Select which equipment failed/malfunctioned (Select all that apply):
Zoll Monitor
AED
Other
Describe the situation in which equipment failed/malfunctioned:
Patient Handoff With ER Staff
Describe the situation below:
Other Medical Related Problem
Please provide details pertaining to the situation:
Submit
Should be Empty: