This form is intended for use by SRJC nursing students and faculty only. Its purpose is to:
1) Gather data about situations that carry risk for error;
2) Develop the user's ability to analyze error risk and to plan to minimize that risk;
3) Track data about errors and near miss involving SRJC program participants.

Students and faculty should complete this together. 
This form is not to be used in lieu of a SRJC conference note or completion of required facility reporting mechanisms.
DO NOT INCLUDE INFORMATION THAT IDENTIFIES PATIENTS OR CAREGIVERS INVOLVED.

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1. Role of person completing this survey (Required.)

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2. Was a student directly involved with this error/near miss event? (Required.)

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3. In what course did this good catch, near miss or error event occur?

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4. When did this good catch, near miss or error event occur? (Required.)

Date

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5. What facility did this occur at? (Required.)

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6. What unit of the facility did this error occur? (Required.)

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7. If a student was involved in the good catch, near miss or error event, who was supervising the student? 

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8. Please describe who was involved in the good catch, near miss or error event?  For example: Student, Instructor, Resource Nurse, Pharmacy, etc. (Indicate the person's role, rather than their name). (Required.)

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9. Situation - Please describe what happened. For example: Early/Middle/Late in the course, patient was in urgent need, med was late, wrong dose supplied, conflicting information received, intervention on wrong patient, sources of distraction were involved, etc. (Required.)

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10. Equipment Involved (if any)

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11. Were there any relevant institutional and/or SJRC Nursing Polices and Procedures followed? If so, what were they? If not, why not? (Required.)

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12. How do you think this near miss or error event might have been prevented? (Required.)

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13. Is there anything else you'd like to share about this event?

T