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 staffing, the quality of care and the safety of patients and nurses have been jeopardized.
The ANA Code for Nurses holds the nurse responsible and accountable to their patients for the nursing care provided. However, responsibility and accountability for the level of care also resides with the Hospital, including both Hospital and nursing administrative staff.
The accompanying "Assignment Despite Objection" (ADO) form may be used to document an assignment which is potentially unsafe for the patients or staff. This form should also be used to document concerns about potentially unsafe conditions that may arise when a nurse may be required to delegate inappropriately to unlicensed assistive personnel (UAPs). This will not exonerate you from liability or responsibility, but it will shift a great deal of the burden onto the shoulders of the Hospital, where it belongs.
Do:
- 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.
Do Not:
- 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 that you have 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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