UE Event Form Template

Complete within 1 hour of event.

Event Details

• Event date:
• Event time:
• Unit/room:
• Patient identifier:
• Vent day at event:

Immediate Clinical Context

• Primary reason for intubation:
• RASS immediately prior:
• Sedation/analgesia at event:
• Restraints present: Yes/No
• If yes, intact/circumvented:
• ETT securement method:
• ETT depth prior to event:

Event Classification

• Suspected primary etiology:
  • Patient factor
  • Mechanical factor
  • Provider/process factor
• Reintubation required: Yes/No
• If yes, time to reintubation:

Contributing Factors (Free Text)

Immediate Corrective Actions

Required Signatures

• RN name/signature/time:
• RT name/signature/time:
• Provider name/signature/time: