Med errors: subpoena, copy of incident report

Nurses General Nursing

Published

Why can't a nurse make a copy of the incident report (of the medication error the nurse made) as a personal file? Yet, she can keep a writing note of the incident. The NCLEX-RN rationale is that the nurse can be subpoenaed in court ? (it's a NCLEX-RN question and rationale that I don't understand). I don't understand? Help would be greatly appreciated :nurse:

Up Vote Up Vote ×
Specializes in OB/GYN, Peds, School Nurse, DD.

i've never heard of that. I make copies of EVERY incident report i make. If something ever goes to court, the prosecuter will subpoena those records along with the medical records. The incident report is my insurance that 1) it doesn't get swept under the rug by someone higher up and 2) gives me some documetation to refer to in the situation that I'm ever served.

Up Vote Up Vote ×
Specializes in Psych.

Could it be that an incident report is an internal document and is not part of the patient's chart?

Up Vote Up Vote ×
Specializes in CVICU and Trauma.

Ok, I've wondered this EXACT thing before too! I recently had to write a TWO med error reports on my new unit manager and I am experiencing some retaliation as a result. I was told I could not make a copy, not even if I kept it in my locker at work. As for taking personal notes of the incident, I did do those but I could not put the patient's name d/t HIPAA. If I was called into court in a year I would NEVER remember the patient's name!

So how is any of this personal documentation saved for personal record?

I'm curious what everyone responds on this post!

GB

Up Vote Up Vote ×
Specializes in FNP.

I never heard that. I never bothered, but no one ever told me I couldn't. I don't even know how they would know what I did with it while it was in my possession.

Diarising patients is a colossally bad idea. It is a double edged sword that a skilled litigator can use against you just as (if not more) effectively than you can use it in your defense.

Up Vote Up Vote ×
Specializes in Professional Development Specialist.
i've never heard of that. I make copies of EVERY incident report i make. If something ever goes to court, the prosecuter will subpoena those records along with the medical records. The incident report is my insurance that 1) it doesn't get swept under the rug by someone higher up and 2) gives me some documetation to refer to in the situation that I'm ever served.

Really!? Because I am a newer nurse, just over 1 year and have filled out dozens upon dozens of incident reports. Find a new 1 cm x 1cm bruise on a patient that someone left off the admission assessment, incident report. Random skin tear on a 90 year old with paper skin? Incident report. Technically if the lab does a blood draw and it leaves a bruise, I need to fill out an incident report. Should I really keep a copy of every incidence report? I'm not asking to be snotty or rude, just thinking I missed something important.

For NCLEX, maybe you shouldn't "technically" make copies because you should trust your employer and that is an internal only document that isn't part of the patients file. If it was part of the patients file then it would be a hippa violation. Either way it would be a hippa violation I suppose. Personally if I had a thought it would end in a lawsuit I would copy it without thinking twice. But that is the difference between NCLEX and actual real life!

Up Vote Up Vote ×
Specializes in ICU/CCU, PICU.
Really!? Because I am a newer nurse, just over 1 year and have filled out dozens upon dozens of incident reports. Find a new 1 cm x 1cm bruise on a patient that someone left off the admission assessment, incident report. Random skin tear on a 90 year old with paper skin? Incident report. Technically if the lab does a blood draw and it leaves a bruise, I need to fill out an incident report.

WOW.

Up Vote Up Vote ×
Specializes in ER, Pediatric Transplant, PICU.

Incident reports are not a part of the patients medical record. It is an internal communication within the facility, so it isn't something that is part of the patients medical record. It's a way to notify risk management or whomever needs to know to follow up. It isnt charted because, if there ever was a lawsuit, since it is an internal document, it doesn't go. However, if you mention it in your notes, its fair game to the lawyer, which can open up more problems.

I do know this is a US thing mostly and may be different in other countries

Up Vote Up Vote ×
Specializes in FNP.
Really!? Because I am a newer nurse, just over 1 year and have filled out dozens upon dozens of incident reports. Find a new 1 cm x 1cm bruise on a patient that someone left off the admission assessment, incident report. Random skin tear on a 90 year old with paper skin? Incident report. Technically if the lab does a blood draw and it leaves a bruise, I need to fill out an incident report. Should I really keep a copy of every incidence report? I'm not asking to be snotty or rude, just thinking I missed something important.

For NCLEX, maybe you shouldn't "technically" make copies because you should trust your employer and that is an internal only document that isn't part of the patients file. If it was part of the patients file then it would be a hippa violation. Either way it would be a hippa violation I suppose. Personally if I had a thought it would end in a lawsuit I would copy it without thinking twice. But that is the difference between NCLEX and actual real life!

Wow. I bet I haven't filled out more than one dozen in 25 years.

Up Vote Up Vote ×
Specializes in SICU/CVICU.

In the United States any records you keep are discoverable in pretrial motions whereas incident reports are not.

Up Vote Up Vote ×
Specializes in ICU/CCU, PICU.
Really!? Because I am a newer nurse, just over 1 year and have filled out dozens upon dozens of incident reports. Find a new 1 cm x 1cm bruise on a patient that someone left off the admission assessment, incident report. Random skin tear on a 90 year old with paper skin? Incident report. Technically if the lab does a blood draw and it leaves a bruise, I need to fill out an incident report. Should I really keep a copy of every incidence report? I'm not asking to be snotty or rude, just thinking I missed something important.

For NCLEX, maybe you shouldn't "technically" make copies because you should trust your employer and that is an internal only document that isn't part of the patients file. If it was part of the patients file then it would be a hippa violation. Either way it would be a hippa violation I suppose. Personally if I had a thought it would end in a lawsuit I would copy it without thinking twice. But that is the difference between NCLEX and actual real life!

I'm sorry this is annoying me too much I have to say something...

That is ABSOLUTELY ABSURD how many incident reports you file. You are just asking to be ostracized by other staff members. Believe me, there is a purpose of incident reports that I fully support, but if I ever worked with you and found out you wrote an incident report over a ridiculous reason then we would have some words.

There's a difference between filling one out regarding potential patient care harm issues and those filled out consequences of medical care with no further interventions needed. Filling one out because of a "new" bruise that the previous nurse didn't tell you about? Did you ever think that bruise maybe happened between the time they gave you report? Writing one about a bruise from a lab draw??? COME ON. There's a difference between a hematoma that formed because of inadequate pressure applied (that would warrant an incident report) and a bruise. Most patients, who are being anti-coagulated, will have a bruise.

I think you need a lot of education not only hospital protocol and procedures, but also nursing in general. You're just flooding the system and crying wolf.

Up Vote Up Vote ×
Specializes in Med-Surg, Psych, Rehab.
I'm sorry this is annoying me too much I have to say something...

That is ABSOLUTELY ABSURD how many incident reports you file. You are just asking to be ostracized by other staff members. Believe me, there is a purpose of incident reports that I fully support, but if I ever worked with you and found out you wrote an incident report over a ridiculous reason then we would have some words.

There's a difference between filling one out regarding potential patient care harm issues and those filled out consequences of medical care with no further interventions needed. Filling one out because of a "new" bruise that the previous nurse didn't tell you about? Did you ever think that bruise maybe happened between the time they gave you report? Writing one about a bruise from a lab draw??? COME ON. There's a difference between a hematoma that formed because of inadequate pressure applied (that would warrant an incident report) and a bruise. Most patients, who are being anti-coagulated, will have a bruise.

I think you need a lot of education not only hospital protocol and procedures, but also nursing in general. You're just flooding the system and crying wolf.

Hey, don't freak out. Maybe this nurse is required to fill out these incident reports. I used to work in a nursing home/rehab facility and was required to fill out incident reports for every skin tear and bruise I found. And I found a lot - and filled out the incident reports for fear of getting in trouble if I didn't fill them out.

Up Vote Up Vote ×
+ Add a Comment