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Maine Sentinel Event Notification and Near Miss Reporting Form This form is required pursuant to 22 MRSA, Chapter 1684, and[removed]CMR Chapter 114, Rules Governing the Reporting of Sentinel Events Use this form to report
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Document Date: 2014-07-15 10:56:40

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File Size: 144,34 KB

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Company

Sentinel / Maine Sentinel / Abduction / /

Event

Product Issues / /

Facility

Facility Name / /

/

IndustryTerm

licensed healthcare / wrong gas / metal object / blood products / healthcare setting / wrong site / /

MedicalCondition

serious injury / injury / intravascular air embolism / burn / electric shock / unstageable pressure ulcers / /

MedicalTreatment

physical restraints / invasive procedure / Surgery / Artificial insemination / medication error / /

Organization

American Society / CMR Chapter / /

Person

Patient / Unanticipated Perinatal / Permanent Loss / /

/

Position

AM/PM / Major / physician / nurse / nurse / pharmacist / Reporter / /

Product

drugs / devices / /

Technology

MRI / /

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