Benchmarking Quarterly Data Submission Form

Facility Name:           

Report Period Information:

Quarter:        1st  2nd 3rd 4th

Year:            

Total Number of Documented Medication Errors This Reporting Period:            

Total Number of Documented Patient Falls This Reporting Period:            

Total Number of Patient Days This Reporting Period:  

  Hospital (Acute Care, Swing Bed & Newborn Days)

Submitted By:           

Phone #:            extension:           

e-Mail Address: