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Variance Report    
Your Last, First, MI    Your Title
Department *Hospital
Email Address *Event Location   
*Date of Event  eg.11/30/2018 *Time of Event  eg.9:23 AM
*Patient Last, First, MI     *Patient DOB  eg.11/30/2018
Room Number *MR Number
Assigned Medical Service
*Was Incident Drug Related?
*Was Incident Fall Related?
Is Variance Laboratory Related?
Is Variance Radiology Related?
Is Code Related?
Is START Related?
Is Inappropriate Admit?

Description of Occurrence    
*Patient Harm Identified    
*Description of Occurrence

 Optionally send read-only email of Variance to Director / Administrator / Head of Department for Shreveport hospital
Directors Administrators Department Chairman

Patient Safety Evaluation System (PSES) is the collection, management, or analysis of confidential information for reporting to or by a PSO. The PSES exists anywhere patient safety activities are conducted and where the use of Patient Safety Work Product may result in quality improvement. The PSES for University Health includes the variance reporting system.