About Incident Reports

Nurses General Nursing

Published

I was told that 3 days after a patient left his lawyer requested all hospital records and incident reports over a nosicomial problem. (Don't want to get too detailed.)

I wrote a pretty incriminating incident report, that,while true, guarantees I'll get a supoena. What bums me is I feel my privacy is violated in that there should be some kind of private internal reporting system that allows for documentation. My incident report set in motion a chain of events that eventually helped the patient, but no one will see that part.

The big defense lawyers with lobbiests with deep pockets have gotten their way.

I wonder if this means nurses are going to be less inclined to make incident reports. We have a private line we can report ethical delemmas, so I guess I'll have to start using that.

Mainly, I'm just venting.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
AGREE AGREE AGREE...100%!! I mean really, who is going to freely and openly report every single mistake/misunderstanding KNOWING THAT DOING SO would MEAN THAT THEY WOULD BE FIRED!!!!!!!!!!!!

Not only that, but knowing that doing so puts it in the hands of a lawyer.

I would like to see SirI's opinion on this. All of us are going on what we have learned. Can we get more info about this new law?

Specializes in Rehab, Med Surg, Home Care.

I find it shocking that a lawyer would have access to an incident report written by a staff member under the understanding that it was an internal document only. The implications of this are pretty alarming!

I still don't understand why everyone is hung up on the incident report being part of the record that an attorney sees. The incident report DOES NOT matter in whether or not you get called for a deposition, named in a suit, or have to testify at trial.

The court may or may not allow an incident report to be turned over to an attorney and even if it is, it may not be allowed in court. There are specific rules governing admissibility which non-legal people are not knowledgeable about.

As a legal nurse consultant, I am looking for the facts. I don't care if you weren't assigned to the patient in question. I will be looking at the staffing sheets to see ALL the staff scheduled and present. I will be looking for comments (verbal or written) that indicate the nurse in charge of the patient talked to another nurse about the patient. Since I know that nurses talk and people all over the hospital hear things, I will suggest to an attorney to explore this and if the person being deposed answers the question the way I anticipate they will, the law allows that avenue to be pursued.

Whether your name is actually on an incident report or on a chart is by and large irrelevant.

Attorneys can be sued for malpractice. By not looking for all the hidden names of people who might know something about a case, might be involved in a case, etc. they are not doing their jobs. Everyone complains that attorneys have to "go after" everybody just because they are greedy. Attorneys are doing their jobs to the best of their abilities, just like nurses.

Frankly, if you are a nurse and allow unsafe practices to go on - you are a potential target. If you have any knowledge of anything, whether you are involved or not - you are a potential target. If you show up to work and take money to take care of people - you are a potential target.

If you want to be safe, ensure that you always follow policy, standards and guidelines. If you deviate from them, you better have a really good reason why. If you employer wants you to deviate from them, you need to stand up and say NO. There are too many people being harmed by unethical and sometimes illegal practices and nurses are not doing anything about it because they want to keep their jobs. There's a choice, keep a job or keep a license......

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

RN 1989, I understand and appreciate what you're saying. However, if incident reports aren't all that necessary for their case, why did your powerful peers lobby and get the law changed? (At least here in Florida).

I feel some things should be allowed to be on the record between us and not the public.

However, I only reported the truth and I have nothing to hide because the truth is always the truth.

I know it's important to write an incident report, it helps to put details together. Those details can be used to insure that everything was done to keep pt safe and it can also bring about change so that a similiar incident doesn't happen again.

One of the most important things to do is to notify family of an incident. Keeping family informed of situations keeps them talking to you. Unfortunate events do happen, and we need to be able to answer their questions so they don't get upset and seek other ways to get their questions answered.

Wow, I too had no idea. Troubling . . . .

steph

if incident reports aren't all that necessary for their case, why did your powerful peers lobby and get the law changed? (At least here in Florida).

I feel some things should be allowed to be on the record between us and not the public.

My guess would be that many facilities try to hide things and tell nurses NOT to document what happened in the nurse's notes. Attorneys KNOW something happened but can't get to the truth because everyone is trying to hide it. Apparently many people can't handle the truth!

I can't tell you the number of times I have seen charts that have absolutely no mention of an incident that harmed a pt, like a simple fall that resulted in skin tears, that was not documented in the chart because the nurses were afraid of either "punishment" from the boss or a lawsuit.

Nurses need to stop being afraid. If you are practicing safely, have good assessment and documentation skills, there is no reason to be afraid to write in a chart what occurred.

Most of the time when there are problems, it is usually a system failure, not an individual nurse's incompetence!

I don't understand why you feel the need to have documents that are not seen by the public. What is the purpose of hiding an incident report? If you work for an employer that puts money and politics ahead of patient and staff safety - I think that incident reports should be freely shared with the public.

Attorneys are not vindictive people that are out to get everybody. I am not out to get people by assisting attorneys. For every medical malpractice/negligence case that actually goes to court or settles out of court, there are THOUSANDS of other cases that never get taken up because they are a crock.

A good attorney and a good LNC can read the documentation and realize when a patient is just being a jerk. But when everyone tries to hide behind paperwork and keep their names out of the situation, that just further hinders the ability to see if there is really an issue or just an unfortunate incident - or someone is just causing trouble.

Because nurses have lived in fear for so long, healthcare has become this writing den of vipers where everyone tries not to get bit by hiding things. If you don't want to be suspected of doing wrong, don't try to hide things. Be open and honest.

And the most important - stop allowing the facilities to get away with murder! Nurses are the last line of defense to keep the public safe from the greed of a corrupt healthcare system. And nurses are failing the public as a whole because they are so afraid to lose their jobs.

If your loved one was the victim of some kind of mistake, I am betting you would be all up that attorney's rear to get every piece of paperwork the hospital had to find out what went wrong and why.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I agree with most of your points. Incident reports should not be used to cover up the truth or the process that lead to an error and that all charting should be truthful and we shouldn't be afraid of the truth.

We'll agree to disagree on other points because there is still some things that should be allowed to be discussed in private before their presentation to others, since not all patients who sue are victims and not all lawyers are patient advocates.

We were taught that if a mention in the patients chart or record was made of an incident report being filed then the incident report became "discoverable" and could be asked for by the attorneys. So if a patient fell, you don't document in the chart that an incident report was written. You write what you want to say in the progress notes and don't mention any other reports being written. I always wondered about it though...

During my career I have been instructed to "look over my notes and change the errors I made concerning certain events." Each and every time the event was a physician who did not respond to a call when a patient took a severe turn for the worse. I refused to change the note, had evidence to show I called as much as 15 times without an answer, ended up calling an ER doc for help. Instead of the doc being reprimanded, I was. So maybe, just maybe, if these docs know a lawyer will see their lack of care, they will do the job they are paid so well to do. Thank goodness the ER docs were on my side, especially when something routine went very wrong and I would have been hung out to dry without support from them and a couple of coworkers. Nursing is a tough job, isn't it strange we all love it so much. LOL. Blessing to all.

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