This form is intended for use by SRJC nursing students and faculty only. Its purpose is : 1] To gather data about situations that carry risk for error, 2] To develop the user's ability to analyze error risk and to plan to minimize that risk, and 3] To 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.