Patient/family Safety Liaison Encounter Form printable pdf download

Patient/family Safety Liaison Encounter Form

Patient/Family Safety Liaison Encounter Form

Patient name: _________________________________ MRN ___________________

Patient Advocate/Champion

:_________________________

Patient/Family Interviewer:_____________________ Date of interview:_______________

Room/Chair______________ Unit:___________________

Prescreen completed (OK to approach patient per Charge RN):_____

Introduction: Hello, my name is ______ and I am a patient/family member (add in type of disease/area

if you wish). We are currently working on this unit gathering some information from patients with

regard to their perceptions of care, specifically about safety. Are you comfortable talking with me today

about your experience here at______?

IF YES and they want to participate--------Let them know that if you receive any information that

the study/care team deems critical to the safety, well-being or improvement of care, the study/care

team has the responsibility to communicate this information to the appropriate staff at the

organization for action.

Length of time receiving care at organization:

0-<6 months

6 months- <1year

>1-<3 years

>3-<5 years

>5-10 years

>10 years

Do you have a primary provider outside of this organization?

YES

If yes, does this organization effectively communicate with your primary provider?

YES

DO NOT KNOW

NOT IMPORTANT TO PATIENT

1. Have you experienced anything today or in the recent past that you would perceive as unsafe

within your plan of care?

Please describe as much detail as possible:

2. Would you have brought this incident to anyone’s attention if I had not inquired about this

today?

YES

Who? _________________

Explanation/Who then?/Why not?

Patient Safety Rounds Toolkit

Patient/family Safety Liaison Encounter Form