Patient Safety Reporting Form (ADO)

Patient Safety Reporting Form (ADO)
Name *

First NameLast Name
Email (do not use work email address)*
example@example.com
Phone Number
By providing my mobile phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my mobile phone on a periodic basis. SE IU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.
Department/Unit*
Indicate the type of unit that you work in and the location of your unit (for example "Tele, 2 South" or "ICU, 2nd Floor"):*
Shift*
Hospital*
If you selected "other hospital" please list below
Unsafe Assignment Information
Is this an urgent workplace safety issue or something that needs immediate response?*
Date and time of incident*

MonthDayYear
Date
Hour Minutes
Patient Room Number
Patient Acuity (overall)*

AverageHigh
Describe the acuity using the options below (select all that apply):*

VentsDripsRestraintsConfusion1:1Frequent Neuro ChecksFrequent Accu ChecksTrach patientsViolent/CombativeTotal CareHigher than normal acuityOther (please describe)
Concern/Violation*

Assigned more patients than Title 22 RegulationsPatient acuity not taken into accountIn my professional/critical judgement this assignment is unsafe and places patient(s) at riskReduction in support staff (NAs, Clerks, Transport, EVS, RT, techs)Use of the buddy systemUnable to take meal or rest breaksLack of adequate/appropriate training for assignment - Does not hold appropriate competenciesDifficulty observing isolation protocolDifficulty observing HIPAA patient privacyCompromised judgement due to fatigue related to the above concernsOther
Because I could be disciplined for refusal of unsafe assignment, I will carry (or have carried) out work to the best of my ability.*
Due to RNs being out of ratio, the following occurred (select all that apply): *

Medications not given/not given on timeTreatments not given/not given on timeTotal care patients turned less than every 2 hoursPoor glycemic control due to food/medications not being on timePatient fallPatient pressure injuryEmployee workers comp injuryVitals not monitored appropriatelyHigher use of chemical/physical restraintsIV medications not titrated appropriatelyUnable to take meal or rest breaksOther
Additional details and reporting information
Describe, in detail, the impact on patient(s). Include any other event(s) that adversely affected patients. Was there potential or actual negative patient outcome?*
Was your supervisor (House Supervisor, Manager, Director) notified about your unsafe assignment in writing?*
Name of supervisor notified:
Method of notification (text, email, fax, or other method in writing - please specify)
Was an incident report filled out?*
Select "Yes" if you intend to send a copy of your signed form to your supervisor. (You will automatically receive a confirmation email with your responses.)
Upload evidence to support your complaint.

Please upload evidence for your complaint here. You may include staffing sheets, schedules, text messages with assignments, or anything else you believe is relevant to your complaint. If you are submitting anything that includes patient information, please make sure to cover it or redact it before uploading, to avoid any potential HIPAA concerns.
Upload a file from your computer or mobile device.

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Do you give SEIU 121RN permission to forward this report to the California Department of Public Health (CDPH)?*
As a patient advocate, in accordance with the California Nurse Practice Act, I will send this completed form to my supervisor to notify hospital administrators, as well as to any other relevant parties. I submit that, in my professional judgement, today's assignment and/or other workplace conditions are not in accordance with California's Title 22 regulations and raise patient safety concerns.
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Patient Safety Reporting Form (ADO)

Unsafe Assignment Information

Additional details and reporting information

Upload evidence to support your complaint.