Patient/family Safety Liaison Encounter Form Page 2

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3. Does staff confirm 2 methods of identification (MRN, name, DOB) whenever you are having
blood drawn, a diagnostic test or medication administered?
Yes
No
4. Do you understand how to take your medications at home?
(***If patient answers no, notify RN for education before this patient leaves today***)
Please describe in as much detail as possible:
5. Do you know what the expected side effects are of your medications?
(***If patient answers no to either of these questions, notify RN for education before this patient
leaves today***)
Please describe in as much detail as possible:
6. Do you know who and how to call in an emergency situation? (***If the answer is no, notify RN
for education before this patient leaves today***)
Please describe as much detail as possible:
7. Do you have any additional comments that you would like to pass on to the safety team to help
us in our efforts to continually improve the delivery of safe, quality patient care?
Please describe as much detail as possible
Patient Safety Rounds Toolkit

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00 votes

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