Provider Preventable Conditions (PPCs) Reporting Form Patient under 21 years of age? Yes No Patient Name: Medical Record Number: Patient Address Street Address: City & State: Zip: Name of Facility: National Provider Identifier (NPI): Type of Facility: Inpatient Outpatient Outpatient Address Street Address: City & State: Zip: PPC – Other Provider Preventable Condition (OPPC) in any health care setting Date of OPPC: Wrong surgery/invasive procedure Surgery/invasive procedure on the wrong body part Surgery/invasive procedure on the wrong patient PPC – Health Care Acquired Conditions (HCAC) in an acute inpatient setting Date of HCAC: Air embolism Blood incompatibility Catheter-associated urinary tract infection Deep vein thrombosis/pulmonary embolism Falls/trauma Foreign object retained after surgery Iatrogenic pneumothorax with venous catheterization Manifestations of poor glycemic control Stage III or IV pressure ulcers Surgical site infection Vascular catheter-associated infection Person Completing This Form Name: Title: Phone: Email:
