Patients For Patient Safety US

First Name:

Last Name:

Best Contact Email:

Preferred Phone:

Who are you?:

Where are you from?:

Do you belong to any organization or group focused on patient safety?:

If YES, please tell us who:

Who is the subject of the story (e.g. who experienced harm in patient safety, who observed non-compliance, with attestation, who is leader morally challanged in governance, etc.) . E.g. "you, your brother" (Please do not include the name of the person harmed):

In what kind of healthcare facility or setting did the harm (or other event) occur. (Please do not include the name of the facility):

Using the Patient Safety Structrual Measure (PSSM) to which domain and Attestation Statement does your story pertain? (Choose only one, even if your story could pertain to more than one):

What is your story?:

Contrast your experience to "what if" the hospital had in place the PSSM specific to the PSSM Attestation selceted:

(Optional) Does your story also pertain to other PSSM Attestation Statements? If so, please explain:

YOUR STORY

Your Story Form