Workplace Naloxone Incident Debriefing Form
In addition to an incident report form to be completed immediately after a workplace naloxone overdose incident occurs, you should get staffers involved to debrief you on the effectiveness of the response. Debriefing should occur several days after the incident, say 7, so there’s time for staff to collect their thoughts and reflect. Here’s a template debriefing form that you can require authorized staff to complete.
Instructions: Complete this Form 7 days after a workplace naloxone incident occurs.
| Actions to Be Taken | Target Completion Date | Person Responsible | |
|---|---|---|---|
| Was the need for assistance clearly communicated before the incident? | |||
| Was the need for assistance clearly communicated during the incident? | |||
| Were roles and responsibilities understood by all team members? | |||
| How are staff members involved in the incident coping? | |||
| What went well? Why? | |||
| What didn’t go well? Why not? | |||
| What can we do better next time? |
Additional Comments/Suggestions:
Authorized Staff Member: Date: