Inciden Report Etiquette

[AliRae]

I had to write my first incident report today, and I'm just not sure if I handled the whole situation properly.

Background: Patient is a 9 month old infant who has been with us since day one (never home). He's quite fragile ... look at him the wrong way and, if he has an IV, it blows. He had a rough night yesterday, febrile, GI issues, and was made NPO with IV fluids for a few hours to give his gut a rest. When I came in in the morning, the report I got was, "His hand looks a little red. You'll probably be able to see it better during the day. It the IV has great blood return, so it's fine." I walked into the baby's room, touched his hand, and he screamed. I stopped his fluids, turned on the light, and saw that the IV was totally infiltrated, phlebitic to the point of his skin starting to peel! Took it out, (after which he was afebrile the rest of the day), gave him some TLC, and told the charge nurse. (Round our parts, it's a big deal when this kiddo loses an IV ... everyone gets told so we can gird our loins to find the next one.) She told me right away to write up an incident report. So I did.

NOW, here's the thing ... when the nurse came in again after my shift, I told her his IV had infiltrated and told her what had happened. She immediately said, "No, it looked fine. He had fluids running for hours, and nothing was wrong with it. His temp was because of his GI issues." So I shut up at that point and didn't mention the incident report. I just didn't want to get into it with her at the end of a long day.

Was this the way to handle it? Something tells me it wasn't. Should I have told her that I wrote up the report? Was there a better way to have approached the situation to get across my feelings of frustration with the way she handled him overnight? Another nurse told me I was overreacting because I'm "too attached" to the baby. Given the fact that he's set to go home on Tuesday for the first time EVER, I think an infiltrate like that was a big deal, because this boy doesn't need any more setbacks.

I'm still new at this nursing thing (15 months into my oh-so-long career), so any input is appreciated.

(PS, I can't spell ... could a mod please correct my subject line?)

[PANurseRN1]

I wouldn't have told her that you wrote her up. It's really up to the supervisor/NM to address that.

[miko014]

I don't know how your incident reports are set up, but we don't use names in ours. If I have to write something up, it's very "RN did this, pharmacist did this", etc. As for any disciplinary action that would result from it, if it was a serious human error that caused a problem, the charge nurse and manager would discuss it first, and then talk to the writer or the incident report - I'm sorry "unusual occurrence report" - and interview those involved and go from there. But the stuff we write up is very "facts only" and details what happened without mentioning names (except the pt - their name is at the top, but we refer to them as he/she/pt in the actual form). You *can* type names into the explaination, but you're not supposed to. You are supposed to put your name at the end, though, so they can come to you if they have questions.

[kitty=^..^=cat]

Incident reports aren't meant to be punitive -- an IV infiltrated. It happens. You aren't saying anything about the nurse, you're just reporting something that needs to be passed along to the manager, quality and risk management.

What if, say, within a month 18% of your IVs infiltrated? All different people taking care of them? Wouldn't you want someone looking to see if there's a problem with the device itself, a specific shift, or group of circumstances and following up to see what's really going on?

Incident reports are just part of the job. They SHOULD be no big deal.

=^..^=

[SCRN1]

Incident reports aren't meant to be punitive -- an IV infiltrated. It happens. You aren't saying anything about the nurse, you're just reporting something that needs to be passed along to the manager, quality and risk management.

What if, say, within a month 18% of your IVs infiltrated? All different people taking care of them? Wouldn't you want someone looking to see if there's a problem with the device itself, a specific shift, or group of circumstances and following up to see what's really going on?

Incident reports are just part of the job. They SHOULD be no big deal.

=^..^=

That's about the same thing I was going to say. I work with adults and know their IVs can be fine one minute and infiltrate the next. With a baby, I would imagine the swelling would happen even quicker than with an adult because of size of the patient. So, the IV very well could have looked fine while the other nurse was responsible for the baby and could've infiltrated during the time it took for her to give you report and then you going to assess the baby.

I had to write an incident report just two nights ago because a doctor told me to. He'd given an order that wasn't done. It didn't get done only because the department responsible for that order was closed by the time the order was put into the computer. I talked to the supervisor about it and here's how we decided to write it....

Incident report per request of Dr. "X". Order for doppler studies of bilateral lower extremities written at 1230. Order entered into computer at 1545. Endoscopy/Biomedical Department closed at 1500 and doppler studies not done by 2100 when Dr. "X" called for results. Called supervisor who contacted on call Endoscopy employee to come in. Doppler studies completed at 2230 and results called to Dr. "X".

Now, this doctor had not written that this was a STAT order or for it to be done now. So, that chart wasn't given any priority over the other stack of charts that were placed at the secretary. I know 3 hours is a long time to get the orders in. But, I was told that it was a really crazy day with "tons of admissions and discharges" and the secretary was steadily putting in orders as fast as she could, amongst keeping an eye on the monitors, answering phones & call lights, and all the other things they get bombarded with.

There is a part on our incident forms that asks what could be done to prevent this incident from occurring. I wrote in that if an order is urgent or STAT, MD should write the order as such and raise the red STAT tab on the chart so the secretary can see to put such orders in first.

[nservice]

At my hospital it is policy that incident reports be done on all infiltrated IV's. Of course, compliance with this policy is low. I have trouble getting my nurses to write an incident report when dopamine infiltrates...but that's another story.

As for this situation, I really doubt that the IV was "fine all night" or she wouldn't have reported that it was red and, "You will be able to see it better in the day". Sounds like she didn't turn the light on to assess the IV site.

[AliRae]

Our incident reports are def. factual ... no names and such. I think my question wasn't so much whether or not I should have written up the report; my head nurse told me to, and so I did it. My wonderment here is more whether or not I should have approached the other nurse to let her know that I wrote it up? Should I have voiced my concerns to her about the fact that that amount of swelling could not have happened in the 1 hour between when she last charted that she checked it and when I first looked at it? Is there a sensitive way to do that? I tend to be very non-confrontational.

[PANurseRN1]

Our incident reports are def. factual ... no names and such. I think my question wasn't so much whether or not I should have written up the report; my head nurse told me to, and so I did it. My wonderment here is more whether or not I should have approached the other nurse to let her know that I wrote it up? Should I have voiced my concerns to her about the fact that that amount of swelling could not have happened in the 1 hour between when she last charted that she checked it and when I first looked at it? Is there a sensitive way to do that? I tend to be very non-confrontational.

No. Again, if there is to be any counseling regarding this matter, it should be done by your NM. Going to the nurse with the comments above would be very confrontational.

Just let it lie.

[cardsRN]

incident reports are not meant to be punitive. that said, our nurse manager receives a copy of every incident report generated in her units (must be a lot with how some of those girls can nitpick). and i'd be a fool to think that she didn't let that color her perception of one's work. that said, if i ever wrote up an incident that i did not directly witness (generated by previous shift) i would definately tell the other nurse about it. and hope she or he would pay me the same courtesy. it's just good to know what sort of things are flying around with your name attached- makes your practice more careful, one could argue. it does not have to be critical or confrontational. remember (and encourage the other nurse to remember), it is not about you or your feelings on the matter- it's about pt. safety.

[AliRae]

remember (and encourage the other nurse to remember), it is not about you or your feelings on the matter- it's about pt. safety.

I like that idea. I'll definitely use it in the future. =)

[P_RN, ADN, RN]

To me this is the reason those lines on occurrence reports are so tiny.

Never volunteer opinion.

Name_______

Where occurred_______

bed rails up etc -that's on all of them (you can answer or you can put n/a)

Objective statement of occurrence?.

On mm/dd/yyyy at 00:00 oclock noted patient baby x right hand was edematous at IV site. Notified NM after removing the IV. Dr notified

What was done to remedy situation?

Rt hand wrapped in warm/cold cloth after IV device renoved.

#27 IV catheter inserted in left firearm with good blood return and confurmation device was working.

Did you notify doc. [yes]

Did you receive new orders [yes] Restart IV put cold or warm cloth on edematous hand

signed_____________RN

Were there any witnesses __________________RN/LPN

ANd then I take a postit note and write my opinion like I don't think it could have gotten this bad in a 15 mi nute report, but......

No official condemnation, accusations.

[hollyvk, BSN]

The purpose for incident (aka variance/occurrence) reports are multiple:

1. Communication to management and administration of adverse events (including events that may trigger complaints to acceditation/licensing entities).

2. Method for tracking adverse patient events to look for patterns and trends.

3. Tracking and notification to hospital Liability Insurance company for events likely to trigger claims or legal action.

4. Evidence of additional education or training needed by caregivers or other staff.

5. Quality improvement parameter tracking (e.g. patient falls).

Only objective info should be documented in the medical record, e.g. "0730--patient found with white, edematous left hand with PIV running at 20 mL/hr. Pt cried vigorously when hand touched, hand cool to touch. IV infusion stopped, PIV catheter removed, hand elevated. PIV restarted in left foot with 24 gauge angiocath."

HollyVK (formerly of risk management)