Incident report filing....How do you do it? - page 2
Night Owl started a very interesting discussion about incident report filing. We were discussing it in another thread, so I decided to take the discussion to another realm. We're just curious how... Read More
Jul 10, '03Night Owl that was a rough one. I thought the whole point about incident reporting was that it should be about a blame free culture and reduction of clinical risk.
I made a shocking error last night. I work in ICU and when I was changing my patient's ET tapes. I accidentally cut through the ET cuff tubing. Had to extubate the patient, manually ventilate him and get the anaesthetist to re-intubate. His O2 sats were 96-99% throughout and thankfully he was an easy re-intubation - Thank God or I would be heading to the library with a silver revolver. So yes I did fill in an incident report. The charge nurse was really supportive and kind and said the report could be anonymous, but I just put my name on it. I also spoke to the patient's relatives in the morning and explained what I'd done. They were fine about it, just glad he was OK. All of my colleagues were supportive to me. I called work a short time ago and spoke to the nurse I handed over to this morning. The patient is OK and his relatives are still fine about it. The consultant anaesthetist then called me and told me not to worry about it on my days off and enjoy my days off, we all make mistakes and everything is fine.
I am so lucky to work there.
The nursing assistant last night cracked me up. She said the last person who was perfect got crucified anyhow!
Jul 13, '03Scotty,
Not to worry at all. I've known a couple people to do this on my floor. We actually have what is called a pilot balloon repair kit, which is used to repair your balloon in case you do cut that cuff off. Personally I've never had to use it. On the last person it happened to, I think they tried to use it, but they just ended up reintubating because the ETT was old anyway. It's not hard when your working with ETT's so much to make that kind of mistake, so don't beat your self up about it. The last nurse that did it on my floor was actually a resource person, smarter than heck, changed the tape a guzillion times, and it was just a simple mistake, and that's how it was looked at.
Jul 13, '03I loved hearing all of your opinions since I am a new grad.
Thanks Scotty for admitting "cutting the tube" , but I think you did all of the correct things!!, As a new grad, alot of nclex practice questions want to know WHEN you would file an incident report, I see that I file one when I make a med error , or when someone falls.
I'm still confuses regarding finding a med error that happened on another shift? Do I need to fill out an incident report on that?
and wow!! atownsendrn's story told of a very astute ER nurse!
Jul 14, '03At my last hospital, I hated these forms because they were very long and redundant. At my current job, they are short, to the point and don't take forever to complete. Needless to say, I complete more now than I used to. It also helps that my manager really does believe they are to be used for process improvement and not to penalize anyone. I really haven't completed a lot of incident reports, but it just so happens that I had two of them waiting for my manager this morning. Last night, the ER sent up a pt with the wrong antibiotic hanging. This happened to be right about the time that another pt pulled out his udall catheter and gave himself a blood bath.
Jul 22, '03By filing them in a drawer thrown in with a bunch of other papers!
Guess what I found last night? Four IR's filled out, both original and carbon copies from june just thrown in a drawer and never turned in! Isn't that Lovely. The other nurse I work with took them and said, "We're going to have some fun with these!" and gave her evil laugh. She's such an instigator, bless her heart!
Jul 22, '03The biggest problem we have with the filing of incident reports is a computer program that is NOT user friendly. There is very little fear of punishment, etc. because we make a very conscious effort not to use them in that way. The surgeons like to demand an incident report when they are unhappy because they want to punish someone but it just doesn't work that way. Most people who don't file reports just don't want to struggle with the computer. If we had a better program we would have better compliance.