ADO - OFNHP PeaceHealth

1
You are filing documentation of unsafe staffing and will generate a report that will go to both your union and your manager. This form is not HIPAA approved - Please do not provide PHI (confidential patient identifying information) in this form.* This field is required.
2
Are you employed by PeaceHealth Medical Center?* This field is required.
Yes
No
3
Oops! It seems you've chosen the incorrect form. Please click here to file an ADO at KP.
4
Which type of issue would you like to report?* This field is required.
Staffing Issue
System Failure
Equipment Problem
Missed Break(s) and/or Lunch
Mandatory Overtime
Not Oriented to Unit
5
What factors contributed to your staffing issue?* This field is required.
Insufficient staff on shift
Department staffed with untrained and/or unqualified personnel (e.g. orientation)
Patient acuity/sickness is higher than planned
Patient intensity/workload is higher than planned
Census is higher than planned
Unit activities (e.g., discharges, admissions, transfers) are different than planned
Support staff different than planned
Inappropriate assignment for skill level
Lead unable to complete lead duties due to patient volume/acuity
Other
6
System Failure(s)* This field is required.
Computers
Medication dispensing machine
Medication bar coder
Call system
Other
7
Equipment Issue(s)* This field is required.
Equipment was unavailable
Equipment was substandard
Equipment was broken
I needed specialized equipment
I wasn't trained or experienced in the area assigned or to the equipment assigned
There was an issue with supplies
Other
8
Did you miss any breaks?* This field is required.
Meal Break 1
Meal Break 2
One rest break
Two rest breaks
Three or more rest breaks
Nope
9
Were you asked to work beyond your scheduled shift?* This field is required.
Yes, I volunteered to stay
Yes, I was required to stay
No, I wasn't
10
Did your issue compromise patient care?* This field is required.
Care Delayed
Care Denied
Medical Error (or near miss)
No, it did not
Other
11
Please explain how patient care was impacted: Include as much detail as you can for the staffing committee to review. No PHI.
12
Were you harmed, or was there a serious threat to your health and safety?* This field is required.
Yes
No
13
Please Explain the health and safety impact on staff:* This field is required.
14
Please describe the incident and explain your concerns. Report the date, time, and duration of incident as applicable. It is helpful to include context like the number of patients waiting and special acuity. Also, how can the concerns be prevented in the future?* This field is required.
15
Date of Incident* This field is required.
Date
Month
Day
Year
16
Shift* This field is required.
Days
Evenings
Nights
17
Actions Taken:* This field is required.
I notified a supervisor
I filed an incident report (if appropriate)
A safety stop was initiated
This was resolved on my shift
No action taken
18
Your Name* This field is required.
19
Your Email* This field is required.
example@example.com
20
Job Title* This field is required.
21
Hospital* This field is required.
Sacred Heart Medical Center; Riverbend/University
PeaceHealth Southwest
PeaceHealth St. John's
22
Select OFNHP Organizer* This field is required.
Vancouver: Jacob Faatz, Ian Jackson
Longview: Jacob Faatz, Ian Jackson
Eugene: Leslie McKenna
23
Dept/Unit* This field is required.
24
Supervisor/Manager's Name
25
Supervisor/Manager's Email
example@example.com
Should be Empty: