Use this form to document patient safety related reporting due to Staffing, Title 22 Violations, Missed Breaks, etc
Do not include any protected patient information in this form. Please fill out as much as you are able. All sections do not need to be filled in to submit.
Your Information
Facility
Please Select
Sf General Hospital
Laguna Honda Hospital
Primary Care Location
Other
Unit
Please Select
Med-Surg (inc. tele & stepdown)
Telemetry
OR/Pre-Op
Pediatrics
ICU
ED
In-patient Psych
L&D
Nursery
SNF
PES
Post-Partum
Cath Lab/GI Lab
PACU
Jail
Primary Care Clinic
Street Medicine
Community Site
Other*
*Unit (if other)
If you selected "other" in the unit dropdown menu above, please specify
Shift
Please Select
AM
Swing
PM
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Names of any other RNs co-signing this form
Cell/Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email (a copy of this completed form will be sent to you)
*
example@example.com
Concern/Violation
(Select all that apply)
Patients were admitted/transferred without the provision of additional staff
Assigned more patients than the Title 22 regulations (see reverse of this sheet for ratios)
In my professional/critical judgment this assignment is unsafe and places patient(s) at risk
Patient averaging: RNs responsible for the LVN’s patients
Patient acuity not taken into account or indicates need for transfer to higher level of care
I am being asked to do something unsafe. I will carry out the unsafe assignment to the best of my ability because I cannot refuse the assignment without facing discipline.
Lack of Equipment/supplies causing inadequate or delayed patient care
Lack of adequate/appropriate training for assignment
Late administration of meds/procedure, delayed response to call lights or patient care (Core measures)
Compelled to work beyond my scheduled hours (ex. mandated)
Floated to an area in which I haven’t received orientation
Required to provide 1:1 patient observation without being relieved of other patients (i.e. covering coaches)
CN assigned to provide coverage for breaks/lunch/transport, RNs transporting pts, and/or
CN had to take a patient assignment
RNs floated to another unit, leaving their assigned unit short
Reduction in support staff: NAs, Clerks, Transport, EVS, RT, techs, other
Inadequate patient coverage during breaks/meals
Difficulty observing isolation protocols due to lack of equipment/staffing/education/timing
Difficulty observing HIPAA patient privacy
Patients were transferred without appropriate level of monitoring (ex. MEA transferring potentially unstable pt or pt that requires monitoring)
Assigned more patients
Missed breaks*
*If you selected missed breaks above, which were missed?
1st break
2nd break
Lunch break
Type of unit & additional information:
Have these types of violations occurred on this unit before?
Yes
No
Was the House Supervisor (AOD), Nurse Manager, or Director notified?
Yes*
No**
*If yes, who was notified?
First Name
Last Name
**If no, please indicate the reason:
Please Select
No manager available
Fear of retaliation or hostility
Other
Was the actual or potential harm to patients and/or staff? (if yes, describe below)
Yes
No
Describe in detail the impact on patient(s) and staff. Include any other events that adversely affected patients and/or staff. Was there potential or actual negative patient outcome? Be sure to observe all HIPPA and patient privacy requirements. Please type your response below:
Unit Staffing & Census (optional)
Total # of patients:
R3/1:1
Patient Acuity (overall)
High
Average
Low
# of RNs providing direct pt care:
# of break RNs:
# of Charge RNs on duty:
# of RNs floated:
# of Flex/Acuity RNs on duty:
Transport services available:
Yes
No
# of CNAs on the floor:
# of Coaches:
# of Clerks on duty:
Submit
Should be Empty: