OFNHP KP Outpatient

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 *
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.
Should be Empty:

ASSIGNMENT DESPITE OBJECTION

INCIDENT INFORMATION