Self Reporting

This form will be used when the following occurs by an LFR member:

• ​Medication Error

• ​Scope of Practice Deviation

• ​​Skill Proficiency/Deficiency

This form provides an avenue of self-reporting an incident to align with medical direction requirements. It will also allow us to trend errors which allows the formulation of remediation initiatives when indicated.

In no manner is this form an attempt to provide disciplinary action against personnel. It is simply a tool used to provide required information to the medical director as well as a method to measure errors. The facts and circumstances of each incident will be reviewed to determine what (if any) corrective action is appropriate.

Completing this form satisfies all reporting requirements as set forth in "Automatic Notification of the Medical Director" in the current Protocols.