The purpose of this Incident Report form is to document workplace issues that do not fall under an Assignment Despite Objection (ADO) Form. If you believe you have been given an inappropriate assignment, you can find the ADO Form under the "Resources" tab. This form serves to record the situation and provide data that KUNA will use to address the issue with you.
A nurse placed in an uncomfortable situation has an obligation to take action. In the interest of themselves, fellow nurses, and patients, they should promptly file an incident report to document the event and have a record of their side of the story. In the event of disciplinary action or other consequences from the hospital, detailed documentation can be crucial.
Report the incident chronologically, including all relevant details. Small details— such as times, locations, and witnesses—can make a big difference. Your name or incident report will not be shared with the hospital without your permission.
If you have any questions, call (913) 963-0067
This form is for you and your union to document unsafe situations. It is not sent directly to KU Med. Your name will not be shared with KU Med management unless you ask it to be.
Instructions
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.
Attach additional pages if needed.
If you need help filling out the form or have other questions, please contact the KUNA Staff Rep.
Abril Negrete: (913)-963-0067