Northwest Region Prehospital Care Program

Self Report Form

INSTRUCTIONS FOR USE

Self Reports (SR’s) can be completed by Paramedics, Management or others wishing to report a concern or variance. Please complete in as much detail as possible to provide context for full analysis. Note: please don’t include any patient health information (PHI) in your responses.

To report an issue related to a Patch, please click here

Name(*)

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Your Email

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EHS #

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Service

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Date of Call(*)

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Call #

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Type of Issue

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Please describe the issue

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Please describe the situation

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What is your understanding of the expected standard of care in this situation?

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Where there any barriers, personal or otherwise, that affected the delivery of the expected standard of care?

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How will you modify your practice to prevent a recurrence?

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How can we help prevent others from repeating this occurrence?

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Verification(*)

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Ontario EMS and Base Hospitals work in collaboration to ensure safe quality pre-hospital patient care is provided to every patient.

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Self Report Form

INSTRUCTIONS FOR USE