Incident reports: Who uses, completes and where do they go??? - page 2

Doctors and nurses are responsbile for improving quality and promoting patient saftety. Use of incident reports has increased since starting proactice....but do people really really use them to help... Read More

  1. by   pickledpepperRN
    If there is an order on the chart couldn't the incident report be subpoenaed?
  2. by   cdmadere
    I suppose they could, but it is not the nurse's responsibility to write an incident report that the MD wants written. You are to write an incident report for something you witness only, and feel is a reportable incident. It is the MD's responsibility to write his own incident report if he feels it is necessary.
    And yes, it could be subpeonaed sp? , which is why they are TAUGHT just as nurses are TAUGHT to not write that in the chart, and to NEVER include a copy of an incident report in the chart.
  3. by   prmenrs
    "...I'm sure I could entertain for hours with the incident reports I've written up."

    Well, I sure found what you DID write absolutely hysterical! Very, very bad, mind you, but very funny in a very warped and twisted way.
  4. by   prmenrs
    The think about incident reports is that they are INTENDED to alert Risk Management/Quality Assurance, etc., that a problem has occurred (or MAY occur) that puts the institution @ risk for liability.

    You are not reporting someONE. Most errors occur because of a flaw in the system. The purpose of incident/occurrence/quality variance reports is to determine where the process breaks down.

    For example: 2 infants died because they rec'd (in error) a huge dose of Heparin. The pharmacy had refilled the PYXIS machine w/the wrong strength. The nurse grabbed the bottle w/o really reading the label, which was remarkably similar to the correct strength. How many "break downs" were there? The manufacturer for not labeling the vials better. The pharmacy tech for not checking the strength on the vials before loading the PYXIS. And the nurse for not actually looking @ the vial before giving it to the kids. Probably a few more I don't know about.

    We recently filled one out because our ventilators are so outdated that we only have one working ventilator, and we cannot get parts to fix the other one. We can't borrow from another hospital, cuz they have all upgraded. We don't keep babies who need to be ventilated-they are outta here as soon as the transport team can load 'em up. BUT. In order to be licensed as a Level 2, we're supposed to have 2 ventilators. Why? Because twins have more problems and a more likely to be premature. If you only have one, you get to hand bag one of them till the team gets there. Trust me on this, not fun.

    The point is, filling out a Quality Variance lets admin know there's a problem and even reminds them why it IS a problem. QA's are a good thing.
  5. by   frenchfroggyAPRN
    I've written several, One that comes to mind is one I wrote the MD (who thinks he is GOD , Cardiac surgeon ) HE had written an order after giving me a verbal order, the verbal was to D/C the peripheral IV and had written D/C Central IV, of course his handwriting is atrocious. Whe I called him to clarify the written order his comment was "I told that Nurse, to D/C the peripheral IV , what was she doing drinking on the job?" I told him that I was the Nurse and NO I was NOT drinking on the job. He hung up on me. You better believe I wrote his a$$ up. :angryfire Of course four months later i was forced to quit working at that hospital for BS reasons. But I don't regret writing him up. After I turned the report in to my boss, He was soooo nice to me after that.
    Last edit by frenchfroggyAPRN on Jan 13, '07 : Reason: forgot the best part
  6. by   Myxel67
    Some MD's write IR's as a method of complaining about a nurse's performance, but usually is not a situation that increases risk of liability.

    I've completed several and had to meet with attorneys and RM in a couple of cases because of threatened lawsuits. My nurse mgr wants me to write IR when I see insulin being given late--after meal for example. I don't do that, but I do speak to the nurse about it privately.
  7. by   Franksters
    I too have filled out many incident reports in my 17 years as a nurse. I worked at a facility that either ignored the reports, coincidentaly, the ones about docs. Or, they fired someone. Never a doc.

    I work at a facility now that takes the reports seriously (unless they involve docs????). I have seen positive change from reports. I see incident reports as a way to track negative/unexpected outcomes. If tracked, we can find trends and devise a plan of action. I know, I know, sounds like bull*!&$.

    My facility eventually acts when a trend is found. Sometimes it takes a l-o-o-o-o-ng time. I am not privy to this process, but I'm privy to "other processes". Slo-o-o-o-ow.
  8. by   lil-hosp.usa
    Ruby great to know there are honest people out there. At my facility it seems that the one that fills out the incident report is the one who gets in trouble and a bad eval for trying to protect and prevent.
  9. by   SEOBowhntr
    Quote from NRSKarenRN
    Doctors and nurses are responsbile for improving quality and promoting patient saftety. Use of incident reports has increased since starting proactice....but do people really really use them to help improve safety and document unusual occurance?
    Unfortunately, incident reports are only taken seriously at my hospital if a nurse did something wrong. I personally wrote somewhere in the 70's on repetitive pharmacy errors, and I wrote up maybe 1/5th of the ones I saw, only because I didn't have enough time to write all of them up. Now 2 1/2 yrs, later, our DON is wanting to do something about it. Sadly, she didn't want to do anything over 2 yrs ago when I sent a personal letter to her, our CEO, our COO, and the directors of both pharmacy and risk management. And here we are over 2 yrs later, same issues, no solution. If I had a nurse who made STUPID mistakes more than 3-4 times, I'd be having a major talk with him or her. With 7 total pharmacist, and 2 of those were night shift whom I found no errors on, that leaves 5 pharmacist, and over 70 incident reports in about a 3-4 month period. I gave up, because I finally realized that our Risk Management group is WORTHLESS.
  10. by   UM Review RN
    Our incident reports go directly to RM and a copy also goes to the Unit Manager.

    I got results when we were continually getting patients from the ER who should've gone to CCU. The patients would arrive off-tele, off O2, and without a nurse transporting, sometimes with drips or blood hanging, and the transporter would be completely clueless as to the situation, put the patient into a bed, and take off.

    We started to feel like an ER extension unit, except for the fact that we could not pull the critical meds, did not have the staff, equipment, or the docs to order the appropriate meds and treatments fast enough to keep the patient going.

    (This was before we had Rapid Response and SWAT nurses.)

    So yeah, I'd write it up. Then, finally, someone got a clue and started sending those patients to where they belonged.

    We also have to write up any med errors or patient incidents out of the ordinary.

    I just use those to report things to RM. Other stuff, such as rude docs or other personal problems, I "write up" informally to my Unit Manager. Risk Management doesn't usually need to know about this stuff. I wrote up one doc and one or two CNAs for rude/dangerous behavior.
    Last edit by UM Review RN on Feb 7, '07
  11. by   msyolee
    i've written incident reports after talking with the same staff person several times over same kind of med error;or i have spoken with my supervisors and they seem to blow off the med errors or the med error is so profound it can't just be overlooked. in my job setting incident reports are a wake up call before its too late.
  12. by   shellek
    While I was obtaining my BSN my nursing supervisor was too busy to attend incident reports reveiw hospital wide, she asked me to fill in for her. I was the only staff RN in the committee, we only reviewed nursing I.R.'s Dr.'s and pharmacist had their own committees. I was very blessed to had been able to be apart of this especially since I was the only actual hands on RN in the committee and not just a superviser pushing papers and attending meetings. Mostly over time you would recognize names cautiousing us on their skills and amazing enough most reports were on insulin and heparin delivery. Reveiwing charts definately taught and reinforced my skills in charting and I am still having a problem with this "charting by exception" I was trained if its not charted it wasn't done, then after graduating this concept of exception charting came about. So I do tend to over chart but in the long run I am responsible for my actions so I stand firm but do cooperate with the institutions policies. As far as where they go they are locked away within the institution unless it is considered a level 3-4 which is referred onto the state board of nursing. 4 is diversion of meds(such as nurses stealing, meds or items) 3 has to realy affect patient outcomes as could be detrimental to their life. Lawyer are to have no access to the incident reports-unless you chart a incident report was filed-so do not chart that! It is only a back up safety paper trail for the hospital and does identify nurses that may need education updates or possible other actions.
  13. by   Morning-glory
    I work in a psych facility so the incident reports are mostly about the wierd things our residents do. Occassionally we have med errors and that needs to be brought up the chain of command. Staff issues are brought up to the DOC and she deals with the issue, not the personal crap. Teaching, inservices and counselling are the norm at my place. I have worked in other places that used them as punitive tools, but where I am now, they are really great with getting to the base problem.