Here are three hypothetical situations.
#1: You’re helping a post-op patient walk from his bed to the bathroom, and he stubs the big toe on his right foot on the IV pole he’s pushing.
#2: When you check on an elderly patient recovering from a mild CVA, you find her on the floor, her left arm apparently fractured. She tells you she was looking for her dog.
#3: In the process of reconstituting a vial of cefazolin (Ancef, Kefzol) to administer to a patient with pneumonia, you sneeze as you’re about to pierce the vial’s stopper to add sterile water, nicking your thumb with the needle.
If you were the nurse involved in any of these scenarios, would you file an incident report? In all three cases, your answer should be yes.
An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member or visitor—is injured or involved in a situation with the potential for injury, an incident report is required.
Many nurses complain that these reports are more trouble than they’re worth. Typically, the loudest outcry comes from nurses who sustain minimal injuries that do not affect anyone else but find that they must submit a report anyway. Before you raise your voice in protest, consider the purposes incident reports serve:
To jog your memory
The medical record is patient focused, and facts pertinent to the incident are likely to be left out. So if a claim were filed and the case proceeded to court, which is sometimes years after the event, you or anyone else involved might be hard-pressed to recreate the scene. Though you may not be able to rely on memory alone, you can count on the incident report to refresh your memory.
To trigger a rapid response
An incident report invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident. The report may also alert administration that a hospital representative should talk to a patient or family to offer assistance, an explanation or other appropriate support. That’s an important function because such communication can be the balm that soothes the initial anger—and prevents a lawsuit.
To facilitate decisions about restitution
An incident report also provides vital information the facility needs to decide whether restitution should be made, if personal belongings were lost or damaged, for example. If these reasons haven’t convinced you that you need to take incident reports seriously, here’s one more: As a nurse, you have a duty to report any incident you have firsthand knowledge of. Failure to do so could lead to termination. It could also expose you to liability, especially in cases of patient injury.
What’s in, what’s out
If you’re the one who discovers the incident, or you have been involved in the situation leading up to it and know more about it than your colleagues, filling out an incident report is your responsibility. You’re expected to complete it before the end of the shift during which the incident occurred or was discovered.
In determining that to include and what to omit, concentrate on the facts. Describe what you saw when you arrived on the scene or what you heard that led you to believe an incident had taken place. Put secondhand information in quotation marks, whether it comes from a colleague, visitor or patient, and clearly identify the source.
Also include the full names of those involved and of any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response: calling for help, perhaps, and notifying the patient’s physician. Any statement a patient makes may help to clarify his state of mind, as well as his own contributory negligence. It’s equally important to know what does not belong in an incident report: primarily opinion, finger-pointing, and conjecture.
Do not offer a prognosis, speculate about who may have caused the incident, draw conclusions or make assumptions about how the event unfolded, or suggest ways that similar occurrences could be prevented. If a patient is involved, keep in mind that entering your observations in the nurses’ notes section of the patient’s chart does not take the place of completing an incident report, and filling out an incident report is not a substitute for proper documentation in the medical record.
Record clinical observations in the chart, not in the incident report, and make no mention of the incident report in the patient record. The report is a risk management or administrative document and not part of the patient’s record. If there’s a reference to it in the chart of a patient who files a claim, however, his lawyers may argue that the report is part of the medical record and should be turned over to the legal team.
Incident reports in court
If your facility undertakes an investigation of the incident and you’re asked to speak to an insurance adjuster or attorney, be honest and factual. Fully disclosing what you know early on will help hospital administrators decide how to handle any potential legal consequences. It also preserves your testimony if you’re ever called on to appear in court.
Whether a patient’s attorney can request and receive a copy of an incident report as part of the discovery process and introduce it into evidence in a malpractice lawsuit is subject to controversy. The law varies from state to state. In addition, there are steps facilities can take to avoid it, like making the incident report an integral part of the quality assurance process and labeling it as such.
Still, if the incident report has been filled out properly with just the facts, there is little reason for concern. Only when incident reports contain secondhand information, conjecture, accusations or proposed preventive measures can they come back to haunt you during the discovery process.
A few more examples
Now let’s see what you’ve learned. Would you file an incident report if:
- A visitor leaving a patient’s room collided with a housekeeping cart left in the middle of the hallway?
- A nursing student observing an EKG tripped over the machine’s electrical cord and cut her hand as she tried to stop the fall?
- A confused patient took a tube of nitroglycerin ointment from an unattended medication cart and rubbed it on her leg in an attempt to ease dry skin?
All reportable incidents? You bet.