ASSIGNMENT DESPITE OBJECTION
Report an incident or ongoing concern about workload or staffing that impacts quality of patient care or quality of work life at KPNW. This form is not HIPAA approved. Please do not submit PHI.
INCIDENT INFORMATION
Incident Date
*
-
Month
-
Day
Year
Date
The assignment or work/patient load compromised or potentially compromised patient care because of:
*
Care Delay
Care Denial
Medical Error/Near Miss
Other
The assignment or work/patient was unsafe due to:
*
Insufficient backfill
Floated outside job description
Lack of dept resources
Assigned to an area not oriented
Department staffed with untrained personnel
Inadequate staffing for acuity or work/patient load
Innappropriate skill mix
Other
Did this assignment or work/patient load jeopardize your health and safety or that of your coworkers?
*
yes
no
Describe the situation
*
It is helpful to include context like the number of patients waiting and special acuity. Remember - No PHI.
Employee Name
*
Employee Email
*
example@example.com
Job Title
Building Code
e.g. BVT or EIN. If not applicable, say n/a
Department
*
Please Select
Primary Care
Urgent Care
Specialty Care
Continuing Care Services
Vision Essentials
Regional Advice
Addiction Medicine
Mental Health
Laboratory
Population Health
ASC (Ambulatory Surgery Center)
Rehab
Supervisior/Manager Name
*
Supervisior/Manager Email
*
This is now a required field. If you do not know your manager's email address, enter itsmyunion@ofnhp.org
Was mandatory overtime incurred with this assignment or work/patient load?
*
yes
no
Did you miss or have to work through your lunch?
*
yes
no
Did you miss or have to work through any rest breaks?
*
yes
no
If yes to last question, how many rest breaks did you miss or have to work through?
Enter "one", "two", "three" or "four"
Background
Assessment
Recommendations
Suggest remedy that would improve the situation.
Submit
Should be Empty: