Unformatted Attachment Preview
Texas Board of Nursing
Comprehensive Request for Safe
Harbor Nursing Peer Review
and
Documentation Form
DO NOT FAX OR MAIL THIS FORM TO THE BON
(Please See Instructions Below)
Safe Harbor Peer Review Instructions:
The Nurse’s Request for Safe Harbor must be made before accepting the assignment
(including any point during the work period when the assignment changes) and the request
MUST be made IN WRITING.
An employer or supervisor cannot deny a nurse the right to invoke Safe Harbor whether the
nurse is accepting or refusing the requested assignment [Board Rule 217.20(c)], A
supervisor’s refusal to accept or to sign a nurse(s) request for safe harbor does not render
the request(s) invalid. A nursing supervisor who refuses to allow a nurse to invoke Safe
Harbor can be reported to the Board http://www.bon.texas.gov/about/complaint/html for
violating the nurse’s due process rights under Nursing Peer Review 303.005(g) and Board
Rule 217.20(h).
□
(1) If necessary, submit a Quick Request for Safe Harbor form to the
supervisor making the assignment or directive, or requesting the conduct you
believe is unsafe/violates your duty to keep the patient(s) safe. [Not required
if the nurse has time to complete the Comprehensive Request form at the
time the assignment, directive, or conduct is requested.] ANY WRITTEN
FORM/FORMAT IS ACCEPTABLE TO INITIATE SAFE HARBOR.
REMEMBER TO KEEP A COPY.
Board Rule 217.20 permits a nurse to complete a Quick Request for Safe
Harbor form if he/she does not have time to complete this Comprehensive
Request at the time of the assignment that is the cause for invoking Safe
Harbor. However, the nurse MUST submit information that equates to that
listed in Section I of this Comprehensive Written Request for Safe
Harbor form and Board Rule 217.20(d)(4) by the end of the work period
and before leaving the practice setting. The nurse’s supervisor who
requested the assignment or conduct should complete Section II (1) by
the end of the work period.
□
(2) Nurse’s Right to Refuse an Assignment/ Required Collaboration
A nurse invoking Safe Harbor may engage in the requested assignment or
conduct while awaiting peer review determination unless the conduct or
assignment is one that:
2008; Revised June 2013
1
•
Would constitute unprofessional or criminal conduct, such as fraud,
theft, patient abuse, exploitation, or falsification, or
•
The nurse lacks the basic knowledge, skills, and abilities necessary to
competently perform the assignment. In other words, the assignment
is beyond the nurse’s individual scope of practice, and accepting the
assignment is likely to expose one or more patients to an unjustifiable
risk of harm. For example: a nurse who has only worked in adult
med/surg is floated to the neonatal ICU and assigned total care of a
ventilated infant on multiple vasoactive drips.
Required Collaboration:
Board Rule 217.20(e) and NPA §301.352 provide protections from retaliation for
refusing to engage in conduct or an assignment for the nurse who makes a valid,
good faith request for Safe Harbor. If the nurse refuses to collaborate with the
supervisor or leaves the work setting without collaborating with the nursing
supervisor, the nurse may be acting in bad faith with regard to a Safe Harbor request
and may be reportable to the board.
If the nursing supervisor making the assignment refuses to collaborate with the
nurse in a good faith effort to determine if a safe assignment is possible, the nursing
supervisor may be reported to the BON for acting in bad faith with regard to alleged
violations of Chapter 303 Nursing Peer Review Law, Rule 217.20, and other board
statutes and rules as may apply.
□
(3) Submit the Comprehensive Written Request for Safe Harbor by the
end of the work period and before leaving the practice setting. The nurse(s)
may include other supporting documents at a later time, but the written
comprehensive request must be submitted to a supervisor by the end of the
work period and prior to leaving the work setting. REMEMBER TO KEEP A
COPY.
□
(4) The Supervisor should sign the form and the nurse’s copy, and submit the
form to the Peer Review Chairperson since a peer review meeting to review
the request must be set within 14 days of the nurse invoking Safe Harbor.
This same time frame applies if the nurse agrees to work with a smaller
workgroup of the peer review committee to review the request.
□
(5) Even if a satisfactory solution is worked out at the time; the nurse(s)
still has (have) the option of continuing with the request for a peer
review committee (or smaller workgroup of the peer review committee)
to review and discuss the reason(s) for the request for Safe Harbor. The
nurse(s) may also choose to withdraw their request; however, written
documentation of this decision with signatures must still be turned over to the
peer review chair for record keeping purposes.
Please see BON web page http.bon.texas.gov for additional resources on Safe Harbor
2008; Revised June 2013
2
COMPREHENSIVE REQUEST FOR NURSING
SAFE HARBOR PEER REVIEW (SHPR)
NOTE: ONLY SECTION I (pages 3-6) MUST BE COMPLETED BY THE NURSE WHEN
INITIALLY INVOKING SAFE HARBOR
A nurse’s request for Safe Harbor Must be in Writing, however, use of this form is not
required for a nurse to invoke Safe Harbor. Any request for safe harbor, be it on this form or
in any other written form or format, is subject to confidentiality requirements of NPA (TOC)
§303.006, §303.007, §303.0075, and Board Rule 217.20.
Date:
Time:
NURSE’S REQUEST
□ Check if you completed a Quick Request for Safe
Harbor Peer Review: date
time
(*Skip to #3 and attach Quick
Request Form copy to this Comprehensive Request)
I.
(1)
Location:
I (we) are invoking Safe Harbor and requesting a Safe Harbor peer review for the
following requested conduct or assignment because I (we) believe in good faith that
the conduct/assignment requested would potentially cause me (us) to violate my(our)
duty to maintain a safe environment and provide safe nursing care to a patient(s) or
client(s), or would constitute unprofessional conduct under BON statutes and rules,
or criminal conduct.
I (we) request that a Safe Harbor Peer Review Committee (SHPRC) examine the
facts and evidence of the situation described below to make a determination if
compliance with the requested conduct or assignment is one that would cause me
(us) to place patients at risk of harm, and thus violate our duty under standards
§217.11(1)(B) and (1)(T), or any other BON statutes or rules.
I (we) understand that unless the conduct or assignment requested would constitute:
A.
B.
C.
Unprofessional conduct (Board Rule 217.12)
A criminal act, or
An act that the nurse is unable to perform because he/she lacks the
competency required to provide care that meets minimal standards of
acceptable nursing practice
that I (we) may accept the assignment and carry it out to the best of my(our) ability,
without fear of risking licensure action by the Texas Board of Nursing.
The following nurse(s) hereby attest that we are invoking Safe Harbor:
Print Full Name and Type of License (LVN, RN)
1.
2008; Revised June 2013
3
Nurse’s Signature
2.
3.
[Attach additional names separately in writing if necessary]
(2)
Name of person requesting the conduct or making the assignment (include licensure,
job title or responsibility at the above date/time:
*(3)
Describe your professional or reporting relationship to the supervisor/person
requesting the conduct or assignment on this date/time:
(4)
Describe the conduct requested, or the assignment or directive received (if possible,
attach photocopy if the request is in written form):
(5)
Describe the practice setting (hospital, nursing home, home health, etc.), your
responsibilities, and the resources available to you:
□ Acute Care/Hospital (type of unit)
□ Long-Term Care/Nursing Home
□ Home Health
□ Clinic (type)
□ School Nurse
□ Nursing Instructor/Faculty
□ Community/Public Health
□ Other (explain below)
Position: □ Staff Nurse □ Charge Nurse □ Nurse Manager/Supervisor □ Other (explain below)
(6)
Describe in detail, how the conduct requested would violate your duty to provide a
safe environment and safe nursing care to a patient(s). If the conduct is patient
specific, identify each affected patient by his/her initials and medical record number.
It may be helpful, but is not required, to reference the standards in Board Rule
217.11 you feel may be violated, and the patient safety concerns of the proposed
conduct or assignment. Continue on separate paper and attach if necessary.
2008; Revised June 2013
4
2008; Revised June 2013
5
(7)
Please attach and list below any written materials (documents, forms, policies,
diagrams, records, procedures, published literature or standards from nursing
professional organizations, etc.) that you believe are pertinent to this request for Safe
Harbor Peer Review. If some or all of the attachments are not readily available at the
time this request is completed, they may be submitted to the Peer Review
Committee and noted here at a later date/time prior to or at the time of the peer
review hearing.
(8)
If you think that the conduct or assignment could be carried out (without violation of
your duty to a patient) if modified or if changes were made in the practice setting,
describe the necessary modifications or changes. Continue on separate paper and
attach if necessary.
(9)
Nurse’s Refusal to Accept Assignment Under Board Rule 217.20(g)(2)
Board Rule 217.20(g)(2) requires both the nurse and supervisor to collaborate when the nurse refuses to
engage in the requested conduct/assignment pending determination by the Safe Harbor Peer Review
Committee (SHPRC). If the nurse refuses to collaborate with the supervisor or leaves the work setting
without collaborating with the supervisor, the nurse may be acting in bad faith with regard to a Safe Harbor
request and may be reportable to the board.
If the conduct requested would constitute unprofessional or criminal conduct, collaboration between the
nurse and supervisor is not required, however, any alternative assignment or conduct requested by the
supervisor must not require the nurse to engage in unprofessional or criminal conduct.
I (we) believe in good faith that I(we) cannot accept the assignment requested because
(Mark the ONE Applicable Box Below):
(A)
□
I (we) lack the basic knowledge, skills, and abilities necessary to
render the care assigned/conduct requested at a minimally competent
level. I (we) believe that engaging in the assignment/conduct
requested pending peer review committee determination would
expose one or more patients to an unjustifiable risk of harm.
On
(date/time), the patient safety concern raised by
the nurse(s) initiating Safe Harbor Peer Review was jointly reviewed with
, who is the supervisor who made the
assignment.
2008; Revised June 2013
6
Please provide a description of the resolution of the issue, or the rationale if
unable to agree upon a safe assignment below (attach other pages as
necessary):
Name of Nurse(s) Initiating
(B)
(10)
□
Date/time
Name of Supervisor
Date/time
I (we) believe that the assignment or conduct requested would
constitute unprofessional conduct under the BON statutes and rules,
or criminal conduct such as fraud, theft, falsification of records, patient
abuse or exploitation, etc. See Nursing Practice Act Section 301.452,
Board Rule 217.12, and applicable BON Disciplinary Sanction Policies
http://www.bon.texas.gov/disciplinaryactions/dsp.html
Nurse’s Decision to Sustain or Withdraw Request for Safe Harbor Peer Review
The situation described in either (A) or (B) above has been
□ satisfactorily resolved at this time and for this instance; or
□ remains unresolved at this time and for this instance.
I (we), being the nurse(s) who initiated this request for Safe Harbor, wish to:
□
Withdraw my (our) request for Safe Harbor and for a review by the
peer review committee; or
□
Sustain my (our) request for Safe Harbor and for a review by the Peer
Review Committee (or physician if questioning the medical
reasonableness of a physician order; see separate form) of the
requested conduct, assignment or directive.
2008; Revised June 2013
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II
SUPERVISOR ACTIONS
(1)
Acknowledgment of Receipt of Request for Safe Harbor
Comprehensive Request for Safe Harbor delivered to Supervisor by:
(Nurse requesting Safe Harbor)
Supervisor (name/signature) receiving Comprehensive Request for Safe Harbor
form:
Date:
Time:
Location:
Supervisor’s Comments and Actions
□
See Quick Request Form or other document (describe below) of initial
request for Safe Harbor:
Comments:
(2)
On
(date/time) I delivered the Quick Request (if
applicable) and Comprehensive Request for Safe Harbor along with any
accompanying documents supplied by the nurse(s) invoking Safe Harbor to
the Peer Review Chairperson, who is:
(Name of Peer Review Chairperson)
(Signature of supervisor/title)
III.
(date/time)
REPORT OF PEER REVIEW COMMITTEE
(1)
The Safe Harbor Peer Review Committee met to consider this request for
Safe Harbor as follows:
Date:
Location:
□
(2)
Time:
The nurse(s) requesting Safe Harbor were notified of the above
meeting of the Safe Harbor Peer Review Committee (SHPRC) and
given the opportunity to attend the meeting and offer
testimony/answer questions in relation to this request for Safe Harbor.
(Attach original green card returned w/ or w/o signature, and
copy of envelope w/address mailed to and copy of dated notice
of peer review letter).
The Safe Harbor Peer Review Committee determined on the above
date/time/location that the requested conduct, assignment, or directive:
□
□
Would have/Did violate the nurse’s duty to the patient(s); or
Would not have/Did not violate the nurse’s duty to the patient(s)
2008; Revised June 2013
8
(3)
Rationale for Safe Harbor Peer Review Committee determination:
(4)
On
to the CNO/nurse administrator.
(date/time), this form was returned
Signature of SHPRC Chair or Representative
Signature of CNO/Nurse Administrator
IV.
REVIEW BY CNO/NURSE ADMINISTRATOR
(1)
I have reviewed the SHPRC report and determined on
(date/time) that the peer review committee:
□
correctly determined the nurse’s duty to the patient(s); or
□
did not correctly determine the nurse’s duty to the patient(s).
(2)
Rationale:
(3)
CNO/Nurse Administrator Action:
□
Withdraw or cancel requested assignment, directive, conduct effective
(date)
(time).
□
Modified the request, assignment, or directive as follows:
2008; Revised June 2013
9
□
Made the following changes in the practice setting:
□
Noticed the nurse(s) who invoked this request for Safe Harbor that the
assignment, conduct, or directive stands as originally issued. I realize
that no facility policy or directive from a CNO, nurse administrator,
physician, or any other person can diminish or supersede a nurse’s
duty to his/her patients [Board Rule 217.11(1)(B) and Position
Statement 15.14 Duty of a Nurse In Any Setting].
In accordance with Board Rule 217.20(j)(4)(B), if the CNO or nurse
administrator disagrees with the decision of the SHPRC, the CNO or
nurse administrator must document the rationale for disagreeing with
the Peer Review Committee, and this documentation becomes a part
of the permanent peer review record (see #2 above).
(4)
On
(date/time [must be no later than 48hours after receiving determination from SHPRC]), this form and attachments
were returned to:
□
The nurse(s) who initiated the request for SHPRC determination
(original to nurse); and
□
The Peer Review Chair Person for maintenance with peer review
committee records retention policy (permanent scanned electronic
copy recommended) (copy of Safe Harbor request and attachments).
Signature of CNO/Nurse Administrator
Date
Signature of Nurse(s) Initiating Safe Harbor
Date
Signature of SHPRC Chairperson
Date
2008; Revised June 2013
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V.
SAFE HARBOR PROTECTIONS TERMINATION DATE
The protections from Board of Nursing action on a nurse’s license under Texas
Occupations Code, Section 301.352 and Chapter 303 end for the nurse(s) making
the request 48 hours after the peer review committee’s determination is received by
the nurse(s) who initiated the Safe Harbor [Board Rule 217.20(i)(3)].
In accordance with Board Rule 217.20(e)(2), this does not affect the protections
under the Nursing Peer Review Law section and the Nursing Practice Act section
301.352 relating to a nurse’s protection from disciplinary action or discrimination for
making a request for Safe Harbor Peer Review [303.005(c)(1) and 303.005(h)].
On
(date/time) I received the findings of the Peer
Review Committee in writing as noted in Section IV of this form.
Nurse(s) Who Initiated Peer Review
DO NOT FAX OR MAIL THIS FORM TO THE BON
(Please See Instructions Above & in Board Rule 217.20)
Any request for Safe Harbor, be it on this form or in any other written
form or format, is subject to confidentiality requirements of NPA
(TOC) §303.006, §303.007, §303.0075, and Board Rule 217.20.
2008; Revised June 2013
11
Date
Texas Board of Nursing
SAFE HARBOR QUICK REQUEST FORM
{Remember to Complete Comprehensive Form/Information on Same Day}
Published May 2008 (rev. 9/08)
The Nurse’s Request for Safe Harbor must be made before accepting the assignment (including
any point during the work period when the assignment changes) and the request MUST be made
IN WRITING.
DO NOT FAX OR MAIL THIS FORM TO THE BON
Minimum Required Information to Make Initial Request Invoking Safe Harbor
The following information must be in writing, but may be on any form and in any format provided
it is in writing (includes electronic transmittals such as e-mail):
1.
2.
3.
4.
5.
Nurse(s) Name(s) invoking Safe Harbor;
Date/Time of Request;
Location of requested conduct/assignment;
Name of person/supervisor making assignment or requesting the conduct;
Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and
217.12.
6. Document collaboration between nurse(s) and supervisor {always recommended; required if
nurse(s) refuse assignment/conduct requested}.
REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR (SEE
FORM) REQUIRED PRIOR TO THE END OF, OR BEFORE LEAVING THE WORK
ASSIGNMENT AREA.
1. Nurse(s) Name(s) invoking Safe Harbor:
2. Date/Time of Request:
3. Location of requested conduct/assignment:
4. Name of person/supervisor (and title) making assignment or requesting the conduct:
5. Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and
217.12):
Signature(s) of Nurse(s) Invoking Safe Harbor:
Signature of Supervisor/Person Making Assignment (Note: A supervisor’s refusal to sign this
form does not render the nurse’s request for Safe Harbor invalid):
1
The following portion of this form need be completed ONLY IF the nurse intends to refuse the
requested assignment when invoking Safe Harbor.
A mutual collaborative effort between the nurse(s) and supervisor making the assignment
is required by Rule 217.20(g)(2) when the nurse refuses to engage in the requested
conduct/assignment pending determination by the safe harbor peer review committee (SHPRC)
because the nurse believes the assignment is not within the individual nurse’s scope of practice.
If the conduct requested would constitute unprofessional or criminal conduct, collaboration
between the nurse and supervisor is not required, however, any alternative assignment or
conduct requested by the supervisor must not require the nurse to engage in unprofessional or
criminal conduct.
6.
I(we) believe in good faith that I(we) cannot accept the assignment requested because (Mark the
ONE Applicable Box Below):
(A)
G
I(we) lack the basic knowledge, skills, and abilities necessary to competently
perform the assignment. I(we) believe that engaging in the assignment/conduct
requested pending peer review committee determination would expose one or more
patients to an unjustifiable risk of harm.
On
(date/time), the patient safety concern raised by the nurse(s)
initiating safe harbor peer review was jointly reviewed with
, who is the supervisor who made the assignment.
Please provide a description of the resolution of the issue, or the rationale if unable to
agree upon a safe assignment below (attach other pages as necessary):
Name of Nurse(s) Initiating
(B)
G
Date/time
Name of Supervisor
Date/time
I(we) believe that the assignment or conduct requested would constitute
unprofessional conduct under the BON statutes and rules, or criminal
conduct such as fraud, theft, falsification of records, patient abuse or
exploitation, etc. See Nursing Practice Act Section 301.452, BON Rule
217.12, and applicable BON Disciplinary Sanction Policies
http://www.bon.state.tx.us/disciplinaryaction/dsp.html.
Any request for safe harbor, be it on this form or in any other written form
or format, is subject to confidentiality requirements of NPA (TOC)
§303.006, §303.007, §303.0075, and Rule 217.20.
REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR (SEE FORM)
REQUIRED PRIOR TO THE END OF, OR BEFORE LEAVING THE WORK ASSIGNMENT AREA.
KEEP A COPY OF BOTH REQUESTS
DO NOT FAX OR MAIL THIS FORM TO THE BON
2
N3375 Health Policy & Legal Aspects
Module 4: Reflection Assignment – Safe Harbor
Submit by 2359 (CT) Saturday of Module 4.
Name:
Date:
Overview: Safe Harbor
Due to staffing shortages and the unpredictability of hospital needs, nurses are sometimes asked
to take on assignments outside their normal routines. As a healthcare professional, you must
understand your options when asked to take on such assignments, the risks associated with
accepting some assignments, and the protections afforded you by the law. Reflect upon your
learning about the Safe Harbor protection as well as any experiences you have had in this realm.
Then follow the instructions to download and complete Safe Harbor forms based upon a fictitious
scenario.
Refer to your course readings and lectures as you complete the assignment.
NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor Comprehensive
forms available electronically, download and complete them instead of the Texas forms. Follow all
other directions as stated.
Performance Objectives:
• Explain and apply appropriate options regarding acceptance or rejection of assignments,
including the use of Safe Harbor.
Rubric
Use this rubric to guide your work on the assignment, “Safe Harbor.”
Task
Accomplished
Proficient
Needs Improvement
Part 1
Complete Safe Harbor forms.
(Total 50 points)
Completes both forms
correctly using
information from the
scenario. All forms
copied and pasted onto
template and submitted
on time.
(50 points)
Completes one form
correctly using
information from the
scenario. Forms not
copied and pasted on
template or submitted
separately/10 pts
deducted
(40 points)
Does not correctly
complete any forms
using information from
the scenario.
(25 point)
Part 2
Reflect upon completion tasks.
(Total 50 points)
Clearly and correctly
answers all three
reflection questions.
(50 points)
Answers at least two
reflection questions.
(40 point)
Fails to answer
reflection questions
(0 points)
©2015 UT Arlington College of Nursing
1
N3375 Health Policy & Legal Aspects
Part 1: Completing Safe Harbor Forms
1. Type http://www.bon.state.tx.us/results.asp?q=+safe+harbor+forms into your address bar.
If this link does not come up for you please type in www.bon.state.tx.us and type in safe
harbor forms in the search box.
NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor
Comprehensive forms available electronically, download and complete them instead of the
Texas forms. Follow all other directions as stated.
2. Download the Quick and Comprehensive Forms
a. Click on the title of the form you wish to download.
b. On the Toolbar, select File, then Save Page As, and save it to your desktop
or My Documents.
c. Open the pdf file from where you saved it.
d. On the Toolbar, select Edit, Copy File to Clipboard.
e. Position your cursor in this document below the scenario, then select Edit, Paste.
(The form will lose some of its formatting, but you will now be able to type information
into the blanks in this document. In your actual practice, you may follow this procedure,
OR print the form and complete the hard copy form.)
3. Complete the forms in response to the scenario below, posing as the nurse described in
the scenario. You will only fill out the follow: “COMPREHENSIVE REQUEST FOR
NURSING SAFE HARBOR PEER REVIEW (SHPR)NOTE: ONLY SECTION I (pages 36) MUST BE COMPLETED BY THE NURSE WHEN INITIALLY INVOKING SAFE
HARBOR”
You may have to fill-in some fictitious “facts” of your own to complete the forms.) You must
only submit 1 assignment document, please paste the safe harbor forms in the
assignment as instructed, and do not submit forms separately.
4. Everything must be copied and pasted onto this form.
Scenario: You currently work on a med-surgical unit in a medium-size hospital. The usual nurseto-patient ratio is 1:5, which you feel is a heavy, but manageable, patient load. You arrive for your
7A to 7P shift and are told that, due to several RNs calling in sick with the flu, you will need to take
nine patients. You question if additional staff is available from another unit, and you are told that
administration is attempting to get help for the unit, but that none is available at this time. You then
state, “I will take the assignment, but I must first claim Safe Harbor.”
[Paste the SAFE HARBOR QUICK REQUEST form here.]
[Paste the COMPREHENSIVE REQUEST FOR SAFE HARBOR form here.]
©2015 UT Arlington College of Nursing
2
N3375 Health Policy & Legal Aspects
Part 2: Reflection Questions
After you complete the two forms, answer these questions in the spaces provided.
1. How long did it take you to complete the Quick Form?
2. How long did it take you to complete the Comprehensive Form?
3. Who else must complete portions of the form(s)?
Submitting Your Assignment:
•
Click Module 4: Assignment in the Module 4 folder.
•
Scroll down to Assignment Submission. Click Browse My Computer and
navigate to your Desktop where you saved your paper. Select the final version of
your paper to upload from your computer.
•
Click Submit at the bottom of the Assignment Submission screen and your saved
document assignment will appear in the gradebook with a green exclamation point
that alerts your Academic Coach that your assignment is ready for grading.
©2015 UT Arlington College of Nursing
3
N3375 Health Policy & Legal Aspects
Module 4: Reflection Assignment – Safe Harbor
Submit by 2359 (CT) Saturday of Module 4.
Name:
Date:
Overview: Safe Harbor
Due to staffing shortages and the unpredictability of hospital needs, nurses are sometimes asked
to take on assignments outside their normal routines. As a healthcare professional, you must
understand your options when asked to take on such assignments, the risks associated with
accepting some assignments, and the protections afforded you by the law. Reflect upon your
learning about the Safe Harbor protection as well as any experiences you have had in this realm.
Then follow the instructions to download and complete Safe Harbor forms based upon a fictitious
scenario.
Refer to your course readings and lectures as you complete the assignment.
NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor Comprehensive
forms available electronically, download and complete them instead of the Texas forms. Follow all
other directions as stated.
Performance Objectives:
• Explain and apply appropriate options regarding acceptance or rejection of assignments,
including the use of Safe Harbor.
Rubric
Use this rubric to guide your work on the assignment, “Safe Harbor.”
Task
Accomplished
Proficient
Needs Improvement
Part 1
Complete Safe Harbor forms.
(Total 50 points)
Completes both forms
correctly using
information from the
scenario. All forms
copied and pasted onto
template and submitted
on time.
(50 points)
Completes one form
correctly using
information from the
scenario. Forms not
copied and pasted on
template or submitted
separately/10 pts
deducted
(40 points)
Does not correctly
complete any forms
using information from
the scenario.
(25 point)
Part 2
Reflect upon completion tasks.
(Total 50 points)
Clearly and correctly
answers all three
reflection questions.
(50 points)
Answers at least two
reflection questions.
(40 point)
Fails to answer
reflection questions
(0 points)
©2015 UT Arlington College of Nursing
1
N3375 Health Policy & Legal Aspects
Part 1: Completing Safe Harbor Forms
1. Type http://www.bon.state.tx.us/results.asp?q=+safe+harbor+forms into your address bar.
If this link does not come up for you please type in www.bon.state.tx.us and type in safe
harbor forms in the search box.
NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor
Comprehensive forms available electronically, download and complete them instead of the
Texas forms. Follow all other directions as stated.
2. Download the Quick and Comprehensive Forms
a. Click on the title of the form you wish to download.
b. On the Toolbar, select File, then Save Page As, and save it to your desktop
or My Documents.
c. Open the pdf file from where you saved it.
d. On the Toolbar, select Edit, Copy File to Clipboard.
e. Position your cursor in this document below the scenario, then select Edit, Paste.
(The form will lose some of its formatting, but you will now be able to type information
into the blanks in this document. In your actual practice, you may follow this procedure,
OR print the form and complete the hard copy form.)
3. Complete the forms in response to the scenario below, posing as the nurse described in
the scenario. You will only fill out the follow: “COMPREHENSIVE REQUEST FOR
NURSING SAFE HARBOR PEER REVIEW (SHPR)NOTE: ONLY SECTION I (pages 36) MUST BE COMPLETED BY THE NURSE WHEN INITIALLY INVOKING SAFE
HARBOR”
You may have to fill-in some fictitious “facts” of your own to complete the forms.) You must
only submit 1 assignment document, please paste the safe harbor forms in the
assignment as instructed, and do not submit forms separately.
4. Everything must be copied and pasted onto this form.
Scenario: You currently work on a med-surgical unit in a medium-size hospital. The usual nurseto-patient ratio is 1:5, which you feel is a heavy, but manageable, patient load. You arrive for your
7A to 7P shift and are told that, due to several RNs calling in sick with the flu, you will need to take
nine patients. You question if additional staff is available from another unit, and you are told that
administration is attempting to get help for the unit, but that none is available at this time. You then
state, “I will take the assignment, but I must first claim Safe Harbor.”
[Paste the SAFE HARBOR QUICK REQUEST form here.]
[Paste the COMPREHENSIVE REQUEST FOR SAFE HARBOR form here.]
©2015 UT Arlington College of Nursing
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N3375 Health Policy & Legal Aspects
Part 2: Reflection Questions
After you complete the two forms, answer these questions in the spaces provided.
1. How long did it take you to complete the Quick Form?
2. How long did it take you to complete the Comprehensive Form?
3. Who else must complete portions of the form(s)?
Submitting Your Assignment:
•
Click Module 4: Assignment in the Module 4 folder.
•
Scroll down to Assignment Submission. Click Browse My Computer and
navigate to your Desktop where you saved your paper. Select the final version of
your paper to upload from your computer.
•
Click Submit at the bottom of the Assignment Submission screen and your saved
document assignment will appear in the gradebook with a green exclamation point
that alerts your Academic Coach that your assignment is ready for grading.
©2015 UT Arlington College of Nursing
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