Form 57.75A A_PSPlan.ppt

The National Healthcare Safety Network (NHSN)

A_PSPlan.ppt

Patient Safety Monthly Reporting Plan

OMB: 0920-0666

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  1. Device Associated Module

  1. Locations

  1. CLA BSI

  1. CLIP

  1. DI

  1. VAP

  1. CAUTI

  1. _______________________

  1. _______________________

  1. _______________________

  1. _______________________

  1. _______________________

  1. Procedure-Associated Module

  1. Locations

  1. SSI

  1. Post –procedure PNEU

 

  1. (Circle one setting)

 

  1. _______________________

  1. In

  1. Out

  1. Both

  1. In

  1. _______________________

  1. In

  1. Out

  1. Both

  1. In

  1. _______________________

  1. In

  1. Out

  1. Both

  1. In

  1. _______________________

  1. In

  1. Out

  1. Both

  1. In

  1. _______________________

  1. In

  1. Out

  1. Both

  1. In

  1. Medication-Associated Module

  1. Locations

  1. Microbiology

  1. Pharmacy

  1. _______________________

 

 

  1. _______________________

 

 

  1. _______________________

 

 

  1. _______________________

 

 

  1. _______________________

 

 

 

  1. Multi-drug Resistant Organism Module

  1. Active Surveillance Culturing Option

         

  1. ASC* Process and Outcome Measures

  1. Location

  1. Organism

  1. ASC-Timing

  1. ASC-Eligible

  1. Incidence

  1. Prevalence

  1. _____________

  1. _________

  1. Adm

  1. Both

  1. All

  1. NHx

  1. _____________

  1. _________

  1. Adm

  1. Both

  1. All

  1. NHx

  1. _____________

  1. _________

  1. Adm

  1. Both

  1. All

  1. NHx

  1. _____________

  1. _________

  1. Adm

  1. Both

  1. All

  1. NHx

  1. _____________

  1. _________

  1. Adm

  1. Both

  1. All

  1. NHx

  1. Process and Laboratory-identified MDRO Event Monitoring Option

  1. Location

  1. Organism

  1. **LIME

  1. HH

  1. GG

     

  1. _____________

  1. _________

     

  1. _____________

  1. _________

     

  1. _____________

  1. _________

     

  1. _____________

  1. _________

     

  1. _____________

  1. _________

     

  1. Patient Influenza Vaccination Module

  1. Method A:

        

  1. Method B:

  1. Denominator Level: (Circle One)

  1. Summary

  1. Patient Level

    
          
 

 
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