Safety Learning Report:

Use this form to report any:
Accident / Incident / Near Miss / System Breakdown / Good Catch
Hazardous Situation / Accident Waiting to Happen

These reports are for patient safety learning and are not intended to be used for disciplinary purposes. Report to your supervisor any suspected criminal, intentionally negligent or intentionally unsafe activities.


Please use these guidelines to answer question #7

A. How did this happen?
What was the chain of events?
How was it discovered?
How was harm prevented?
Please include what you believe really caused the problem.

B. What changed as a result of this problem?

C. What were the contributing factors?
What was the work environment like at the time of the situation?

What were the personal or team factors affecting human
performance in this situation (such as inattention,
perceptions, judgments, decisions, communication, coordination)?

D. What could prevent occurrence of this situation?
What did you learn from this situation?
Is there anything that you will do differently in the future?
Who/what could help improve this situation?
What could you see or measure that would show that
FHSM has reduced the risk of this situation from occurring in the future?