| 74081-1 | Patient safety event:ID:Pt:^Event:Nom:AHRQ | required |
| 30947-6 | Date form completed | required |
| 30947-6 | Date form completed | required |
| 74573-7 | Location of patient safety event or unsafe condition:Type:Pt:^Event:Nom:AHRQ | required |
| 74572-9 | Reporter of adverse event or unsafe condition:Type:Pt:^Event:Nom:AHRQ | required |
| 74571-1 | Healthcare professional:Type:Pt:^Event:Nom:AHRQ | conditional |
| 74570-3 | Additional details of event or unsafe condition:Find:Pt:^Event:Nar:AHRQ | optional |
| 74569-5 | Action that prevented the near miss incident from reaching the patient:Find:Pt:^Patient:Nom:AHRQ | conditional |
| 74568-7 | Event was associated with a handover:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74567-9 | Contributing factors for event were known:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74566-1 | Contributing factors for event:Find:Pt:^Event:Nom:AHRQ | conditional |
| 74565-3 | Event was a National Quality Forum (NQF) serious reportable event:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74564-6 | National Quality Forum (NQF) serious reportable event:Type:Pt:^Event:Nom:AHRQ | conditional |
| 74563-8 | Incident preventability:Find:Pt:^Event:Nom:AHRQ | conditional |
| 74501-8 | Patient safety event report - hospital - summary of initial report - version 1.2:-:Pt:^Patient:-:AHRQ | |