incident report

From the sounds of it, this would have essentially happened the same way on my unit. Lab does cancel ordered labs without informing the floor or the MD, most of the time because they were duplicate orders (ex: a CMP ordered after a BMP, so the BMP would be cancelled). To be honest, I do not know our policy on lab cancelling other orders and thats something I will look into. Our incident reports are called "Patient Safety Alerts." When a situation arises where the nurse or charge nurse feels a PSA should be written, the responsibility does fall on the person who found the error to submit the report. They sdefinitely hould look at the situation from every angle before writing the PSA, but it sounds like even though your coworkers did that, they were unable to find what should have probably been easy enough to figure out. After the PSA is submitted, our manager usually will look into it herself and if need be, discuss what happened with that person in private. As long as the situation is resolved, the only people who see the PSA are the person submitting it, person it involves and our manager. That way, in a situation like yours, it is easily taken care of and it does not affect or involve anyone that it shouldn't. We treat them more as learning experiences and use them to identify areas of improvement for the unit as a whole. I hope this helps!

Incident reports at our facility sound very similar to the incident reports described by RNmb. While they can be used against you if a pattern of unsafe behavior is established, for us, they are used to help understand why something happened. They address communication, system or technical errors, education/training deficits, and other issues that need to be addressed. It's a means to track problems, look at issues from all areas, and learn how to avoid such issues in the future.

I've had several incident reports written about me. Every time we have a fall, and incident report is written. Once I miss programmed a PCA pump and delivered 10x the amount of drug to a pt. I caught it at the follow up check; but initially neither I nor the second, verifying RN discovered it. I was one of several nurses who had this issue, and our tech and risk management departments decided it was a programming flaw within the pumps, and recommended we replace them with another design. It led to the purchase of brand new pumps from another company.

Another example: after several incident reports regarding new nurses not following protocols, our floor decided to do an ongoing education with the new nurses, for their first year of employment. Once a month they attend a 4 hour class that reviews what do to in certain situations (chest pain, code blue, hypoglycemia, etc). It is to supplement and reinforce their orientation, and to improve their practice. While they all hate coming to a class, they all also report that it does help them, and incident reports have dropped. It's helped so much that we *all* might have to start attending some sort of on-going orientation on protocols!

I have never felt in fear of my job following an incident report. I have never had one waved in front of my face in a threatening manner. I *have* had our director/assistant director give me the print out and ask me to tell them what happened, why I think it happened, and how I would recommend avoiding the incident in the future. In our hospital, on our floor, it is a genuine process, with the intent to discover problems and improve practice.

It simply means someone made a mistake somewhere and it needs to be explained how and why, and what the end result was, and who was notified.

In your case the lab canceled orders and the investigation needs to be directed to why they did, and how they can do so without the nurse being made aware of it, and maybe the nurse will catch it on a shift chart check. We had an issue at my ICU job for a while where the lab wasn't doing anything unless it was marked stat and the computer was randomly cancelling any order it pleased. Believe me, there was enough heck raised by the floor, ICU and the ER that it took less than a week to fix. In the meantime shift handoff had to include the info that you needed to call the lab and tell them what labs you just put in the computer. It was a headache and a half.

So just make sure when you end up your shift in the meantime, that you double check to make sure lab didn't cancel your stuff. If you notice a trend then write it up and raise some heck of your own.

It sounds like what you did, and how you followed it up were both in the right. Got a question, is this a new computer system to your facility? Is there a policy about LAB canceling orders?

we do a lot of incident reports just to prove our computer system is not the right one for our hospital. So it may be that the incident report is even being generated for a reason you don't even know. I know when we are trying to prove unsafe staffing, the incident reports bump way up.

There are many steps to an incident report. The follow up is one of the big ones. And you gave proof that you did no wrong--and there will always be an audit trail of that in your comptuer system.