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Safe Harbor Forms - Nursing Peer Review

With the revisions to the Nursing Peer Review statutes (effective 9/1/2007) and nursing peer review rules (effective 5/11/2008), new forms have been developed to make the process faster and easier for a nurse who believes he/she is being asked to accept an unsafe assignment, engage in conduct beyond the nurse's scope of practice, or engage in unprofessional or illegal conduct. The Texas Board of Nursing (BON) provides the following three forms which may be used as part of the process (please do not send these Safe Harbor forms to the BON):

The Quick Request for Safe Harbor is an abbreviated form to allow a nurse to quickly jot down the key information necessary to invoke Safe Harbor in writing as required by Rule 217.20 at the time the nurse is asked to accept what he/she believes to be an unsafe assignment. Use of the form is not required, but is provided to make safe harbor an easier process for the nurse.

The Comprehensive Request for Safe Harbor Form is a sample form that may be used to document the more in-depth information that the nurse must commit to writing before leaving the work setting at the end of the work period. The nurse may still supply supporting documents at a later time, however the details of the events surrounding the request must be recorded prior to the nurse leaving the premises. The comprehensive form also includes a fill-in-the-blank format that the peer review committee and CNO or nurse administrator can utilize to document the safe harbor peer review process. Again, this form is not mandatory, but is offered a guide to the process. An entity required to have a peer review plan must have policies and procedures that encompass other aspects both within and beyond the statutes and rules of peer review. In other words, it is not sufficient to use the BON Safe Harbor forms in place of official policies and procedures on nursing peer review.

The third form, Safe Harbor Request to Question the Medical Reasonableness of a Physician's Order, is for those occasions when the reason for the nurse's need to invoke Safe Harbor is related to the actions or orders of a physician. In this case, the nurse may not need to use either the Quick or the Comprehensive request forms, since it will be an individual physician who will make a determination, rather than a nursing peer review committee. In other words, to question the medical reasonableness of a physicians order, a nurse will likely only need to use this third form by itself.

A facility or other entity establishing a nursing peer review plan may establish it's own forms and procedures that comply with the peer review statutes and Rule 217.20 Safe Harbor Peer Review.

You may wish to review Frequently Asked Questions Peer Review, or BON Nursing Peer Review FAQ PDF PDF graphic icon in addition to the above BON Safe Harbor Forms. A Reference Table to help locate rules and statutes relating to peer review topics is also available on the BON's web site under Nursing Peer Review.

Review of the Safe Harbor Peer Review Rule in its entirety is also recommended:

  • Rule 217.20 Safe Harbor Peer Review for Nurses and Whistleblower Protections.

The rules relating to Incident-Based Peer Review include:

  • Rule 217.16 Reporting of Minor Incidents
  • Rule 217.19 Incident-Based Nursing Peer Review and Whistleblower Protections

The rules are accessible on the BON web page at: