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.
The assignment or work/patient load compromised or potentially compromised patient care because of:
Medical Error/Near Miss
The assignment or work/patient was unsafe due to:
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
Did this assignment or work/patient load jeopardize your health and safety or that of your coworkers?
Describe the situation
It is helpful to include context like the number of patients waiting and special acuity. Remember - No PHI.
e.g. BVT or EIN. If not applicable, say n/a
Continuing Care Services
ASC (Ambulatory Surgery Center)
This is now a required field. If you do not know your manager's email address, enter email@example.com
Was mandatory overtime incurred with this assignment or work/patient load?
Did you miss or have to work through your lunch?
Did you miss or have to work through any rest breaks?
If yes to last question, how many rest breaks did you miss or have to work through?
Enter "one", "two", "three" or "four"
Suggest remedy that would improve the situation.
Should be Empty: