| 74081-1 | Patient safety event:ID:Pt:^Event:Nom:AHRQ | required |
| 30947-6 | Date form completed | required |
| 74076-1 | Medication or substance involved:Type:Pt:^Patient:Nom:AHRQ | required |
| 74075-3 | Medication:Type:Pt:Medication:Nom:AHRQ | conditional |
| 74077-9 | Ingredients for compounded preparations:Find:Pt:Medication:Nom: | conditional |
| 74074-6 | Biological product:Type:Pt:Medication:Nom:AHRQ | conditional |
| 30959-1 | Lot # Vaccine | conditional |
| 74073-8 | Type of nutritional product:Type:Pt:^Patient:Nom:AHRQ | conditional |
| 74072-0 | Best characterization of medication or other substance event:Find:Pt:^Event:Nom:AHRQ | conditional |
| 74071-2 | Incorrect action:Type:Pt:^Patient:Nom:AHRQ | conditional |
| 74070-4 | Best description for the incorrect dose:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74069-6 | Best description for the incorrect timing:Find:Pt:^Patient:Ord:AHRQ | conditional |
| 74068-8 | Best description for the incorrect rate:Find:Pt:^Patient:Ord:AHRQ | conditional |
| 74067-0 | Best description for incorrect strength or concentration:Find:Pt:^Patient:Ord:AHRQ | conditional |
| 74066-2 | Expiration date:Date:Pt:Medication:Qn:AHRQ | conditional |
| 74065-4 | History of allergies or sensitivities to the medication or substance administered was documented:Find:Pt:^Patient:Ord:AHRQ | conditional |
| 74064-7 | Medication or substance contraindication - potential or actual interaction:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74063-9 | Stage in the process that the event originated, regardless of the stage at which it was discovered:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74078-7 | Medication or other substance details panel:-:Pt:Medication:-:AHRQ | conditional |
| 74051-4 | Intended route of administration:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74050-6 | Actual route of administration - attempted or completed:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74080-3 | Patient safety event report - hospital - medication or other substance - version 1.2:-:Pt:^Patient:-:AHRQ | |