Concern for Safe Staffing Submitted by odmin on January 8, 2014 - 2:05pm As Nurses and Health Care Professionals we are obligated to speak up for our patients and our practice. The Concern for Safe Staffing form is notice to FAHC that in your assessment, based on your professional experience and knowledge, the staffing complement that you are being asked to work within is unsafe. This form is used in the systematic evaluation of staffing, it is VITAL that prior to submitting this form you communicate your concern to your management team and/or their representative AND collaborate with them to develop a plan to ensure the safety of your patients, coworkers, and yourself. Name Please fill in your full name and the names of any others that share your concerns. Date of Incident Year Year20202021 Month MonthDecJan Day Day12345678910111213141516171819202122232425262728293031 Cost Center Please enter your Department Name or Cost Center Number. This field will autocomplete as you type. So typing in "Baird" will give you all the Baird options, "Shep" all the Shep options, etc. Shift Day Evening Night Length of Scheduled Shift How long was your shift supposed to last? Number of Actual Hours Worked Census at Beginning of Shift Census at End of Shift As a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our assingnment is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patient. As a result, the facility is responsible for any adverse effects on patient care. Brief Statement of Problem If your issue doesn't fit well in the form details below, please use this space to describe your concerns, so we can make the workplace safer for all. Notification You Have GivenYou must notify charge nurse and manger/ANC at the time of need or concern. Charge Nurse Time Response Manager / ANC Time Response Other Time Response FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING CARECheck all that apply. Lack of Experience / Training / Orientation to unit on part of Float Nurse Orienting Nurse Scheduled Staff not replaced Unfilled Position Sick Time Vacation / Holiday Posted Holes / Understaffed Lack of Ancillary Help Secretary / Clerk Transport Housekeeping LDA / LNA Dietary Other Staffing Situation Posed an Actual Threat of Injury Stress Violence Other Staffing Situation Posed a Potential Threat of Injury Stress Violence Other Other Concerns Missed Break and / or Meals Skill mix of staff inappropriate Required to stay beyond shift Unable to delegate / perform / supervise safely due to needs greater than staff available Staffing Provided was Not Adequate to Safely Address Patient Needs Related toCheck all that apply. General Patient Concerns High Patient Census High Patient Acuity Unplanned Patient Events (ie code or fall) Patient Number Concerns Total Number of Transfers Total Number of Admissions Total Number of Discharges Compromises in Patient CareComoromises in patient care necessitated by the staffing situation. Mark all that apply. Compromises in Patient Care Occured due to Basic hygeine, feeding, toileting, positioning, walking not done on time or at all Assessment, observation, monitoring of patients not done as scheduled, jeopardizing patient safety Medication (including IVs) orders not done on time or at all Physician orders not done on time or at all Procedures, treatments, laboratory tests not done on time or at all Communication such as emotional support or teaching with patient/family not completed Inadequate pain management Compromise for Other Reason Staffing Levels Actual Staff Numbers on Duty RNs LPNs LNAs Recommended Staffing Levels in your Judgement. RNs Recommended LPNs Recommended LNAs Recommended Who Determines Staffing Levels? Staffing level is determined by Charge Nurse Nurse Manager Staffing Office Director of Nursing Your Email Address Please provide your email address. We will send you a copy of this form using this address. We prefer to use your personal email address in this field. By submitting this form you are providing notice to FAHC of your dispute for the staffing complement you are being asking to work within. When you submit this form it is submitted to the FAHC director of Nursing (or their designee) and to The Vermont Federation of Nurses and Health Professionals. Thank you for advocating for yourself, your co-workers, and the patients we care for.
