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.
- Verbally notify your unit coordinator/supervisor immediately when you believe you have been given an unsafe assignment
- Complete this form as soon as possible without interrupting your work or interfering with patient care if your unit coordinator/supervisor does not or cannot make a satisfactory adjustment. (This is usually at the beginning of shift or time of assignment, but may occur at any time).
- State that you are accepting the assignment and will carry it out to the best of your ability under the circumstances.
- Use any patient(s) names or identify the patient(s) in any way
- Use this form if you have failed to verbally notify your unit coordinator/supervisor. This form documents you communicated your concerns to a unit coordinator/supervisor
- Use this form indiscriminately
KUNA will tabulate data collected from these ADO forms and use it to promote changes to improve patient care and staff safety.
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