PIRS-2 Incident Report Form

• Good catch / Near miss
  an incident that did not reach the patient*
• Good catch / No Harm Incident
  an incident that reached a patient, but no discernible harm resulted*
• Harmful Incident
  an incident that reached the patient and resulted in harm*
• a patient safety
• a patient safety

* The Conceptual Framework for the International Classification for Patient Safety – WHO 2009

• Setting up pre-prime
• Prime
• Post prime/pre-cannulation
• Post cannulation/pre-CPB
• CPB hypothermic
• CPB normothermic
• Post CPB
• ECMO/VAD/IABP

• Elective
• Emergency

• Seconds
• Minutes
• Hours

• None
• Mild (transient variance not extending LOS)
• Significant (injury prolongs ICU/hospital stay)
• Serious (injury lasting >month & expected to resolve)
• Unknown

• Observed by self
• Alerted by monitor alarm
• Change in monitor sound, trend or display
• Third party