This form is intended for use by SRJC ADN 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.

This form is not to be used in lieu of a SRJC conference note or completion or required facility reporting mechanisms.

DO NOT INCLUDE INFORMATION THAT IDENTIFIES PATIENTS OR CAREGIVERS INVOLVED.

* 1. Role of person completing this survey

* 2. Was a student directly involved with this error or near miss event?

* 3. What course level are you involved with in ADN program?

* 5. What facility did this occur at?

* 7. If a student was involved in the near miss or medication error, who was supervising the student?

* 8. Please describe who was involved in the near miss (good catch) or error:

For example: student, instructor, resource nurse, pharmacy [Indicate the person's role, rather than his/her name.]

* 9. Situation - Please describe what happened:

For example: Early / middle/ late in the course of the rotation, patient was in urgent need, med was late, wrong dose was supplied, conflicting information was received, sources of distraction were involved, etc.

* 10. Equipment Involved [if any]

* 11. Relevant institutional and/or SRJC ADN Policies and Procedures: What are they? Were they followed? If not, why not?

* 12. How do you think this error or near-miss might have been prevented?

* 13. Is there anything else you would like to share about this event?

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