Med errors: subpoena, copy of incident report

Nurses General Nursing

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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:

Specializes in ICU/CCU, PICU.
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.

Well either way, I'm glad I don't work with her.

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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

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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.

She's only following the rules.

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All of the LTC facilities I've worked at were the same way. Every single bruise, skin tear, red mark, etc, had to have an incident report completed along with written statements taken from nursing staff who cared for that resident for the past 24 hours. There were times I'd have 4 or 5 reports to fill out on a single evening shift. Funny how day and night shifts never ever saw or reported any injuries; they were almost always discovered and reported by my evening staff to me, the sup.

In addition, injuries were almost always found and reported during last rounds just before CNAs finished their shift. This caused many LPNs and RNs to get out of work very late on a regular basis. CNAs always got out on time or even a little early.

We just could not keep up with the tremendous amounts of paperwork generated in our own little dysfunctional, broken, and soul-sucking corner of nursing known as LTC. The following day, we'd be scolded for not punching out at 11:30 PM shart thus causing overtime. Admin would pull the better time management game and slap our wrists. It was absurd to go through that every single evening shift I worked. It got real old real fast.

It's true. It really is like that in LTC.

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

Actually, they are. It's just that it is much harder for lawyers to get access to them.

I was told that even personal notes that someone keeps regarding a pt incident are discoverable! Technically....

DeLana

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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!

Where do you work that you even have time to do that?

Anyhow, I was told by the hospital lawyer, that our incident reports are non-discoverable, at least in my state. I'm sure a clever lawyer could figure out how to access them, though.

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I'm thinking it's because an incident report is not "a personal file." It's for the hospital's use, not the employee. I'm sure it happens all the time in reality, but just remember...the NCLEX is not reality (and neither is anything we learned in RN School!)

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Specializes in Emergency, Telemetry, Transplant.
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.

Not that I want to do all those incident reports, but I wish I had that kind of extra time...

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Specializes in Pediatrics and geriatrics.
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!

same here, we do incidents reports for everything and anything. i joke that we even fill em out if the resident farts sideways!! lol

nicenurse lpn

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Not that I want to do all those incident reports, but I wish I had that kind of extra time...

LTC nurses dont do incident reportd because we have "extra time". We do what we have to because management says we have to. I can see how it seems dumb to fill one out for a bruise caused by a lab draw, but you know what's not dumb? NOT getting fired.

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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.

I'm not sure where the nurse filling out incident reports is working but in LTC/SNF you have to fill out an incident report for every single unexpected issue that comes up. Skin tears, bruises, scratches, allergic reactions, etc. etc. etc. That is policy. For some facilities a bruise related to a blood draw would not warrent an incident report, however, it would have to be documented with a nurse's note in the patient chart. I have a patient with a sunburn, guess what? Stubbed toe? Incident follow up.

I doubt the poster is filling out those reports for the fun of it, it's is policy. So while I get your reaction to the poster, I think you need to focus on the culprit, which is the system, not the poster who is trying to do her job.

As for making copies of the reports, I am going to guess that it might have something to do with HIPAA, staff are not allowed to take patient information out of the facility, or to make copies of PHI without authorization. Also, the incident report is a legal document that belongs to the facility. That would be my theory.

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