Sample scenario
Royal Oak · Unit 9S IPR
01
Something Feels Unsafe
You're handed an assignment that doesn't add up for the unit -- the ratio, the acuity, or the skill mix isn't what a safe assignment looks like on Royal Oak 9S IPR today.
Trust your own professional judgment. If it doesn’t feel safe, it’s worth raising.
02
Speak Up First
Before anything gets filed, you tell your charge nurse or supervisor you're taking the assignment under objection, and why. The tool never replaces that conversation -- it documents it.
03
Open The Tool
You start a new ADO right from your phone, on shift, instead of hunting for a paper form or remembering to do it after the fact.
New ADO — Assignment Despite Objection
Sample -- not a real submission04
Fill In What Happened
Assignment details, why it's unsafe, and the staffing picture on the unit -- in your own words and numbers. Here's what that looks like filled out for Royal Oak 9S IPR, one section at a time.
Assignment Details
Campus
Royal Oak
Unit Name
9S IPR
Date of Assignment
03/14/2026
Name(s) of Registered Nurse(s) Objecting
Sample Nurse, RN
Protesting Assignment As
Primary Nurse
Assigned To Me/Us By
Sample Charge Nurse, Charge RN
Time / Shift
0700–1100
Objecting Based On The Following
My/our patient assignment exceeds the staffing matrix or established maximum patient assignment for this unit and shift.
Charge nurse responsibilities may/did not allow time for direct patient care assignments
The unit is/was not staffed with an adequate number of support staff (PCAs, techs, lift teams, 1-to-1 patient sitters)
New patient(s) were transferred/admitted/discharged without adequate staff to care for them
Patient(s) who require a higher level of care are placed inappropriately on the unit
EMR documentation systems override RN judgment and interfere with direct patient care responsibility or do not function properly
Insufficient or faulty equipment or supplies
RN(s) not oriented to or experienced in the area they were assigned or floated to
Patient Care Outcomes Or Nursing Duties Affected
Patient fall occurred
Medication errors/late administration
Inadequate time for assessment, evaluation, monitoring or observation
Unable to meet standards for pressure ulcer prevention
Delayed or incomplete charting/documentation
Breaks not provided for direct-care RNs to prevent fatigue, accidents, and/or errors
RN(s) required to work beyond their scheduled shift
Staff Working
RNs
3
Agency RNs
0
LPNs
0
Aides / Techs
1
Clerks / Secretaries
0
RNs Called Off / Flexed Off
1
Additional Staff Needed
1 RN
Staff Called In
None available
Unit Patient Census
24
Additional Information
Comments
Ratio and acuity exceeded safe staffing for the patient mix. Additional support was requested at shift start but none was available.
Today's Date
03/14/2026
Time
07:14 AM
Incident Report Filed (RL Solutions / SafetyPause)
Yes
05
Submit & Keep Your Copy
Submitting sends it directly to your union representatives and gives you your own confidential copy -- so there's a record no matter what happens next.
Right now, do this the way your contract and your steward already tell you to -- this tool isn’t live yet.
Confidential and sent directly to your union representatives. Never include PHI.
06
Try It Yourself
Curious how it feels to actually fill one out? Go ahead -- this copy is completely separate from the sample above.
Before you try it
This is a sneak peek of a tool still in development -- not a real reporting channel. Nothing you type or submit below is sent, saved, or transmitted anywhere. It stays on this page and disappears the moment you leave it. If you have a real concern about an unsafe assignment right now, talk to your Union Steward instead of using this page.