PRODUCT COMPLAINT FORM

 

To:      Nursing Program Coordinator - Products     
   
        Nursing Outcomes and Education
   
        Rt. 0469

 

From: _____________________________              __________                _______

   Individual Making Complaint                               Extension                   Route

        (Name and Title)

 

_____________________________

     Department Name

 

Date:   _____________________________

 

Product/Equipment:                                                                                                           

 

Manufacturer:                                                                                                                                                                                

Product Number:                                           Lot Number:                                           

                                                                                           Designates a specific "batch
                                                                                           of the product.

 

Please attach sample of defective material and package, when possible.  If product has been used in direct patient care, it should be placed in a sealed container/bag and kept on the unit.  Notify Nursing Program Coordinator - Products for pick-up at ext. 20603.

 

Complaint:                                                                                                                              

                                                                                                                                               

                                                                                                                                               

                                                                                                                                               

 

Recommended Action:                                                                                                            

                                                                                                                                               

                                                                                                                                               

 

Comments:                                                                                                                             

                                                                                                                                               

                                                                                                                                               

Nurse Manager Notified?   Yes___   No___

 

___________________________                              ___________                         ________

Name of Nurse Manager                                        Extension                             Route

 

10/99 P. Townley  Product Complaint Form