# Presentation: 469958

## Patient Safety Monthly Reporting Plan

| * required for saving
 Facility ID:_______________________ |  | 
*Month/Year:______ /______ |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- |
|      No NHSN Patient Safety Modules Followed this Month |  |  |  |  |  |  |
| Device-Associated Module |  |  |  |  |  |  |
| Locations
______________________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ | CLA BSI
 |  | DE | VAP | CAUTI | CLIP
 |
| Procedure-Associated Module |  |  |  |  |  |  |
| Procedures
___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ | SSI
(Circle one setting)
In  Out  BothIn  Out  BothIn  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  Both In  Out  BothIn  Out  BothIn  Out  Both |  |  | Post-procedure PNEU
(Circle)
InInInInInInInInInIn |  |  |
| Medication-Associated Module: Antimicrobial Use and Resistance |  |  |  |  |  |  |
| Locations
______________________________________ ___________________ ___________________ ___________________ | Microbiology
 |  |  | Pharmacy
 |  |  |

**Patient Safety Monthly Reporting Plan**

**Assurance of Confidentiality:**  The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
- Public reporting burden of this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).
- CDC 57.106(Front) Rev. 1

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

## Patient Safety Monthly Reporting Plan

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

| MDRO and CDAD Module |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Locations

ALL     
ALL
ALL
ALL |  |    Setting         Specific     
(Circle one)     Organism 
                       Type          
In  Out  Both  ________ 
In  Out  Both  ________
In  Out  Both  ________
In  Out  Both  ________ |  |  |  | ±LabID                       Event




 |  |  |  |  |  |  |  |  |  |  |  |  |
|  |  |  |  |  |  |  |  | Process and Outcome Measures |  |  |  |  |  |  |  |  |  |  |
| Locations | Specific         Infection 
Organism    Surveillance
Type                                           |  |  |  | §AST 
Timing |  |  |   §AST
 Eligible
 |  |  | Inci-
dence |  | Preva-lence |  |  | Lab ID
Event | HH | GG |
| ______ |  | ________          |  |  | Adm 
Both |  |  | All 
NHx |  |  |  |  |  |  |  |  |  |  |
| _______ |  | ________         
 |  |  | Adm  
Both |  |  | All  
NHx |  |  |  |  |  |  |  |  |  |  |
| _______ |  | ________         
 |  |  | Adm  
Both |  |  | All 
NHx |  |  |  |  |  |  |  |  |  |  |
| _______ |  | ________         
 |  |  | Adm 
Both  |  |  | All 
NHx |  |  |  |  |  |  |  |  |  |  |
| _______ |      ________        
 |  |  |  | Adm Both  |  |  | All  
NHx |  |  |  |  |  |  |  |  |  |  |
| High Risk Inpatient Influenza Vaccination Module |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Check one: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Method A  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Method B  |  |  |  |  |  |  | 

 |  |  |  |  |  |  |  |  |  |  |  |
| 

§For AST, circle one to indicate timing of testing and one to indicate type of patients tested.

Timing: Adm = Admission      Both = Both Admission and Discharge/Transfer

Patients: All = All patients tested            NHx = Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission.

±LabID Event – Laboratory-identified Event |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| 

CDC57.106 (Back) Rev. 1 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |