REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR SEE FORM REQUIRED

Remember to complete comprehensive request for safe

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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 [Paste the COMPREHENSIVE REQUEST FOR SAFE HARBOR form here.] Texas Board of Nursing Comprehensive Request for Safe Har- bor 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 nurs- ing supervisor who refuses to allow a nurse to invoke Safe Harbor can be reported to the Board 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, di- rective, or conduct is requested.] ANY WRITTEN FORM/FORMAT IS ACCEPT-
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2008; Revised June 2013 6 ABLE 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 set- ting. 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: 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.
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