Incident Report

[beeble]

Hello: I am a relatively experienced nurse, and got a job at a new hospital in the new city I’m in.  

I had a patient on a heparin gtt, and per protocol, I stopped the gtt for one hour and restarted at a lower rate during the night.  Just the usual.

I was extremely busy with my two patients (ICU) who were more than anything for the busy- ness was that one needed a lot of attention, and the other had pretty constant coughing fits on the vent.  I put a lot of time and attention into both, and also realized an overall picture for the center patient was that she was having cardiac issues (that had previously not been looked at) and I was trying to figure it out (big picture).

Anyway, I gave report to a float nurse that had a float pool preceptee.  I had thought I did a good job that night, and did a lot of “cleaning up” as I do, from the previous day (I work nights), and generally being thorough.  I am not the type to sit and chat- I’m running between the two rooms, getting my baths done, labs, PRN’s, meds, tubing, etc.

Then I got an email from the manager wanting to talk to me because someone had filled out a “psvr” (safety report).

apparently I had not charted the stop time and start time for that hour of stop and start of the heparin.  At my previous job- we didn’t specifically chart “stop”.  We just charted the rage change when it was restarted and would write a note about stopping it per protocol for an hour.  She also wrote that I didn’t chart the 50cc for a piggyback.  

I just remember being insanely busy with the two patients- the one that needed attention, the other with constant coughing fits— in addition to everything else, and that I had actually left that might thinking I’d done a really good job.

I don’t usually ever go to management about someone else unless it’s pretty serious.  If it’s something more minor, I usually would try to talk to them first before going to management.  

I did fill out a psvr recently for the entire ICU not having a syringe of d50, which is an emergency drug, and the pharmacy refusing to send one for an hour while they insisted one was on the unit (so I spent a whole hour searching the five fridges two- three times.  Anyway that’s an example of where I’d complain.  

anyway now when I see this nurse (infrequent because she is float pool), I get very nervous because it’s like any tiny omission or mistake will be written up.

This morning she came with another preceptee, and I was nervous and I guess I got snarky due to that and told her that I’d better be in my toes because I know she will write psvr’ s anything missed.  She said “well heparin stopped should be charted the time it was stopped” and I said “if I complained about everything then I’d be writing things up constantly”.  I asked her name because I wanted to be aware of who she is in the future (she usually has a preceptee chart everything so I didn’t know).

I don’t know why that bothered me so much or why it feels so threatening.  I probably shouldn’t have said anything, but I also wanted to express to her that wow - like I seriously would be writing everyone up all the time if people expect perfection.  I did not not chart it due to laziness- she could have shot me an email? I want to stay away from toxicity…

anyway- I’m asking for feedback about this? Thanks

[Closed Account 12345]

Your reaction was inappropriate and unprofessional.  You chose to make another nurse uncomfortable, and possibly intimidated, just for the sake of being rude. Your conversation served no productive clinical purpose, nor did it help improve the work environment. I would not be surprised if you end up counseled or disciplined by your manager or HR for your response, and really, I hope that's the outcome. This type of toxic behavior shouldn't be tolerated.

Would I personally write an incident report about this? No. However, the nurse had a legitimate patient care/safety concern. As a float nurse, she might not have had the opportunity to bring it to your attention personally.  As a preceptor, she walked her orientee through your facility's process for reporting patient care/safety concerns. I'm not seeing the problem. 

Nursing 101: If it wasn't charted, it wasn't done. You're no longer employed at your previous job, so that isn't a factor here. Take accountability for your clinical errors. Learn from them.  Then learn how to professionally interact with peers.

Creating an incident report for a genuine concern isn't toxic.  Verbally accosting someone for doing so is toxic.

[JKL33]

5 hours ago, Closed Account 12345 said:

However, the nurse had a legitimate patient care/safety concern.

According to my observations of acute care and coworkers over the years, I believe that ^ is doubtful.  I almost completely disagree with the previous post for that reason. There might be a legit safety concern if one cannot ascertain that the heparin was held (I.e. if there is no indication anywhere that it was), but whether or not that is the nurse's actual concern in a situation like this, where they can clearly see that someone was doing something to follow the protocol, is another matter. The most likely thing is that this report was indeed written because the technical documentation error was observed and no other reason. The OP is correct, there isn't enough time in the day to write reports about things that can't be called serious with a straight face. And you know who doesn't take good/safe care of patients?--People who write those reports, that's who. They're too distracted with their incessant need to feel good about themselves. And although you can't observe that quite as readily as the fact that someone forgot to chart a stop time (?), it wreaks far more havoc and is ultimately far more dangerous for patients to have a busybody nurse who somehow has enough time to worry about such things.

I agree that the OP shouldn't have talked to the other nurse about this, but AFAIC the main rationale for not doing so is because the actions of this float nurse aren't worth the negative emotional energy.

Anyway, moving on.

OP - Crappy places handle safety reports and write-ups as practically one in the same. Which is probably why you refer to this as being "written up." The only answer there is to not work for a manager or company like that. The way management chooses to handle safety reports can be one of the more potentially-toxic aspects of working in the hospital.

[Been there,done that, ASN, RN]

"  I asked her name because I wanted to be aware of who she is"  Doesn't she wear a badge? Doesn't she co sign the preceptees notes?  Sounds like an incident report.

[EOC, MSN, RN]

Every hospital is different and has different heparin protocols. We have to double sign the gtts at the start, bag change, tubing change, and shift change. That's a challenge in itself. If you were so busy, learn to reach out to leadership, charge nurse, or peers on the shift for help. It is very important to keep in mind your high-risk drugs and prioritize what needs to be done. I tell the nurses that handoff is soooo important. That means line reconciliation, gtts, patient condition, etc...If it isn't done you own it. Of course, it was an error if you can't figure out when the heparin was off to turn it back on. I think the preceptor was teaching the nurse what you are supposed to do when you run into these things. I'm curious, don't you have a heparin flow sheet? That should tell you the start and stop times ( unless that wasn't filled out). I know ours do. Yes, you could have handled the conversation better. Turn it into an opportunity for improvement. I would apologize and admit that I should have made sure it was done. Looking for things to improve your and others' workflow is important. This may be something you could bring to your manager and help turn it around for you. Some days at work just suck. We have all had them. Pay it forward to the next person you find who forgets. Nurses need to be supportive of each other too. 

[zoidberg, BSN, RN]

I honestly agree with what you did and here is why. I disagree with safety systems being used this way. It rarely solves anything. If that nurse had an issue, why not bring it up during report? "hey, I don't see a stop/start time on the heparin, can you chart that before you go? Thanks!" It corrects the action in question in real time. Lets be honest, after a shift, im wiping my mind of a lot of what I just did. don't ask me about it in a month. Maybe you could have handled it better but I relate more to you in this situation just because there are so many passive aggressive people who won't say anything to your face but love to fill out reports against you.  

[hppygr8ful, ASN, RN, EMT-I]

One of the things that I have learned and has served me well is that when I am confronted with criticism (personally or professionally) is to ask myself if I own any part of what is being said/reported. If the answer is yes then I must accept it with grace and endeavor to change so that it doesn't happen again. 

That being said I will note that as a senior charge nurse and preceptor I absolutely hate writing incident reports. They are time consuming, rarely serve any positive purpose and usually result in hurt feelings. When something happens that I feel has had an avoidable impact on patient care and the person who made the error is not readily available, then report I must. I am not doing it out of a sense of my own importance, or because I don't like a co-worker or because I think I do more/better than other nurses. Still I have known only a small handful of nurses who don't become defensive and can merely state they appreciate that the error was caught before serious consequences occurred. 

Part of supporting each other as nurses is to point out ways that our co-workers can improve each other's practice to benefit our patients. Better patient outcomes mean improved perception by the public of what nurses do. 

Hppy

[canoehead, BSN, RN]

I would not have written that incident report. I'd have just ignored that fact when interacting with the nurse that wrote it, and I would have pointed out to the manager that if thats the worst thing she could find after 12 hours, I call it a pretty decent day, but yes, I'll write it differently in the future. (sigh)

[JKL33]

On 5/24/2022 at 1:01 PM, EOC said:

Of course, it was an error if you can't figure out when the heparin was off to turn it back on.

The OP turned it back on him/herself, so that was not the reporter's concern.

19 hours ago, hppygr8ful said:

Still I have known only a small handful of nurses who don't become defensive and can merely state they appreciate that the error was caught before serious consequences occurred. 

If someone's opinion about my care  is brought to my attention and they have a point I just say thanks for letting me know. When they are being petty (or worse) I just say "noted." People become defensive because of the numerous reasons people actually write reports and because of the ways reports are handled. And, let it be noted, not all of this is defensiveness--sometimes the "defensive" response is simply an attempt to inform the person that the pettiness is apparent.

On 5/24/2022 at 1:01 PM, EOC said:

If you were so busy, learn to reach out to leadership, charge nurse, or peers on the shift for help.

Not helpful advice given the reported circumstances in most of the country, and the "if you were so busy" reads like an attempt at calling someone's bluff and giving them yet another thing they are probably wrong about.

We do need to strive to do our best, but it is pure BS that people are working in conditions where THE GOAL is to run things as lean as humanly possible, and then several degrees lean beyond possible, but then we are supposed to "own" all of the innumerable minutiae that go "wrong" in such a setting.

NO.

Being able to point to a miniscule thing and say "you did this [X] thing wrong"--especially a thing that is literally only wrong because of some secondary/side-reason--does not create a need for improved morality (owning up) on someone else's part. It's a bunch of BS and a waste of one's time on earth.