1-2 December 2017,  JW Marriott Mumbai Sahar, Mumbai ,India

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Asian Patient Safety Conference Awards 2017– Entry Form

Note:

  • Participants need to fill up the below form for each single entry. One organization can submit more than one entry and can also apply for different categories.
  • This entry template will assist you to ensure that you clearly address all the required information. This is very important for the judges to evaluate your entry.
  • Keep your answers as clear and precise as possible. Please adhere to the word limitations for each section.
  • Don’t forget to attach any supporting evidence, i.e. documents and/or high-resolution photograph or videos of the initiative/project/successful endeavour.

Name of the Project / Initiative / Improvement:

Executive Summary (Max 250 Words):

Project Details:

1. What was the patient safety issue identified? (Max 100 Words)
2. What changes were made to address the issue? (Max 250 Words)
3. How did your organization go about implementing the change? (Max 250 Words)
4. Explain how the changes have resulted in an improvement to patient safety? (Max 500 Words)
5. How have you ensured that the changes are sustained? (Max 250 Words)
6. What are the different quantifiable benefits of these improvement/changes? (Max 250 Words)

Asian Patient Safety Awards 2016

Name of the Project / Initiative / Improvement:
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Executive summary:
(Max 250 words)
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Hospital description:
(Max 150 words):
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Entry Criteria with Your Responses

1)What was the patient safety issue Identified? (Max 100 words)
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2) What changes were made to address this issue?
(Max 250 words)
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3) How did your organization go about implementing the changes?
(Max 250 words)
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4) Explain how the changes have resulted in an improvement to patient safety?
(Max 500 words)
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5) How have you ensured that the changes are sustained?
(Max 250 words)
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6) What are the different quantifiable benefits of these improvement/changes?
(Max 250 words)
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Hospital Name:
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Person Name
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Designation
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Email-id
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Contact No
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Please mention in details the list of attachments (supporting evidences in form of photographs/videos, any other relevant document):

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