The purpose of this form is to notify hospital supervisors that you have been given an assignment which you believe is potentially unsafe for patients and/or staff. This form will document the situation and verify your report. This form will also provide data that KUNA will tabulate and use to address the problem.
A registered nurse receiving an assignment that in her/his professional judgment places a patient(s) or themselves at risk has an obligation to take action. Acting in the interest of patients, the nurse should promptly notify her/his supervisor that because of inadequate