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Question about who is responsible for an incident report

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Specializes in LTC, peds, rehab, psych. Has 8 years experience.

FurBabyMom, MSN, RN

Has 8 years experience.

Primarily, our incident reports are used as internal tracking to evaluate how often specific events happen and look for similarities in events. The MOST I have ever seen after writing incident reports is that I've been emailed by risk management with specific questions. Once a medication was missed/not given, I noted that it wasn't given, asked the attending if they wanted it given when I noted it (they said no) - all of which I documented. But I was not the person who could speak to why - I was not caring for the patient at the time the med was missed and could not speak about that time, only when they arrived to mine. The other time it was related to a defective product and they wanted to know details about what happened to the product once we stopped using it - and as an institution we pulled an entire lot of a supply out of use related to my report.

Some incidents have went for root cause analysis - but there is a reason to do that. It makes sense, we should want to know what happened, why and how it might be prevented in the future. People make mistakes, it is part of being human but if there are lessons that can be learned and reduce the likelihood of something like that happening again - why wouldn't you want to do so? I do know that, in my facility, based off incident reports, policies have been revised, education topics identified for refreshers, stuff like that. Staffing numbers have been changed - it's not all bad or punitive.

I do know that there are differences in institutions - not all institutions treat their staff like ours does us. Where I used to work I probably would have been more hesitant to write some stuff up, because the culture of the institution was different.

Also, if I find an issue - I write it up. I don't write everything up, some of the stuff our risk management department would like written up, ain't nobody got time for that. They would like it if we wrote up every "contamination" event in the OR - and no, I am NOT writing up every time something gets dropped. Implants - yes. Whole trays coming up from CPD contaminated, yes. Dropping an instrument during a procedure? No.

I've wrote up incidents from when I wasn't primary staff, sometimes it's just to help the primary staff out. Piece of equipment broke - failed the test prior to being used (I happened to be around/witness the event). That's easy to help a coworker with the report on - you are just documenting what happened, what you did about it and who was present.

I had another event I wrote up - and because my lunch relief was involved, I documented what they'd told me happened during my lunch (as part of a larger saga of events) in the incident report - simply stated as a "per report from So-and-so, RN".

I don't see what the issue is - so long as you tell the truth. If the truth is that you KNOW something happened but don't know the details - that's all you can admit to.

Edited by FurBabyMom
Forgot a thought...

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 19 years experience.

That is a common belief among healthcare workers, but it is a false one. When there is a survey at your home, administration does not have to produce any incident reports to the state. However, in the event that the facility is sued, either by a private party or the government, an incident report is considered discoverable. Most decent lawyers are aware that making incident reports are a standard procedure for most medical facilities and they will try to gain access to them during discovery.

Good to know. Our administration still pounds the "don't mention it in the chart and it doesn't exist" line, but I always kind of wondered about that. Not a lawyer [obviously] but are they allowed to go fishing for incident reports as discoverable evidence if there is no mention that said incident report actually exists? I watch way to much Law and Order [my hubby is addicted to that show!] and am genuinely curious about this. We need a nurse/lawyer on AN to answer these questions.

VANurse2010

Has 6 years experience.

This kind of BS is why I'll never work in LTC again.

RiskManager

Specializes in Healthcare risk management and liability.

Good to know. Our administration still pounds the "don't mention it in the chart and it doesn't exist" line, but I always kind of wondered about that. Not a lawyer [obviously] but are they allowed to go fishing for incident reports as discoverable evidence if there is no mention that said incident report actually exists? I watch way to much Law and Order [my hubby is addicted to that show!] and am genuinely curious about this. We need a nurse/lawyer on AN to answer these questions.

Well, as the risk manager, I do answer these questions, fill out the interrogatories and get deposed on this. Because there are so many exceptions; specific state statutory and case law unique to each jurisdiction; and the existence of any peer review, quality improvement or work-product privilege; one cannot make a blanket statement that incident reports are not discoverable or incident reports are always discoverable. It all boils down to the facts of the case, the subject matter of the litigation, and if there are alternative means to find the information other than the incident report. Whenever anyone asks me if the incident report is immune from discovery, I always reply: it depends.

I would say that a fairly consistent national trend over recent years has been to chip away at the discovery protection of the incident report. And yes, any plaintiff counsel with experience knows that incident reports are ubiquitous in almost every healthcare setting, and they will often issue a request for product, subpoena duces tecum or the like to try and compel them to be produced.

I ask my staff to fill out the incident reports in a factual manner, with information that allows me to figure out why the incident happened, and I use them to figure out if are there are any lessons I can derive from this in order to change practices to reduce the risk of this incident happening again. Just as I instruct my staff about charting, I ask them to not write anything in the incident report that they would be embarrassed or chagrined to explain in front of the 12 nice people in the jury box or the administrative law judge or disciplinary panel at your license hearing.

Conqueror+, BSN, RN

Has 27 years experience.

I have worked many years in LTC and if I witness a fall I do the incident report. Some facilities let you leave the notifications if it is change of shift. I had a patient from the other hall wander into one of my patients room and fall. Guess who had to do that one ?

ixchel

Specializes in critical care.

Well, as the risk manager, I do answer these questions, fill out the interrogatories and get deposed on this. Because there are so many exceptions; specific state statutory and case law unique to each jurisdiction; and the existence of any peer review, quality improvement or work-product privilege; one cannot make a blanket statement that incident reports are not discoverable or incident reports are always discoverable. It all boils down to the facts of the case, the subject matter of the litigation, and if there are alternative means to find the information other than the incident report. Whenever anyone asks me if the incident report is immune from discovery, I always reply: it depends.

I would say that a fairly consistent national trend over recent years has been to chip away at the discovery protection of the incident report. And yes, any plaintiff counsel with experience knows that incident reports are ubiquitous in almost every healthcare setting, and they will often issue a request for product, subpoena duces tecum or the like to try and compel them to be produced.

I ask my staff to fill out the incident reports in a factual manner, with information that allows me to figure out why the incident happened, and I use them to figure out if are there are any lessons I can derive from this in order to change practices to reduce the risk of this incident happening again. Just as I instruct my staff about charting, I ask them to not write anything in the incident report that they would be embarrassed or chagrined to explain in front of the 12 nice people in the jury box or the administrative law judge or disciplinary panel at your license hearing.

I have really enjoyed your posts and think you're a fantastic asset to our humble little community here. I didn't click your name yet to see if you're new. I've only noticed your posts kind of recently. If you are new, welcome to allnurses, and I'm glad you've joined! If you're not new, I'm sorry my head has been in the sand because I've learned from you in the short time I've noticed you. Anyway, hi! *waves hello*

ixchel

Specializes in critical care.

Okay, I stalked. You are new!

Welcome!

Stick around!

Try not to let us crazier people scare you off. We get weird, but we mean well. :)

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 6 years experience.

We get weird

Speak for your self...Oh wait, I resemble that remark!

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 19 years experience.

Well, as the risk manager, I do answer these questions, fill out the interrogatories and get deposed on this. Because there are so many exceptions; specific state statutory and case law unique to each jurisdiction; and the existence of any peer review, quality improvement or work-product privilege; one cannot make a blanket statement that incident reports are not discoverable or incident reports are always discoverable. It all boils down to the facts of the case, the subject matter of the litigation, and if there are alternative means to find the information other than the incident report. Whenever anyone asks me if the incident report is immune from discovery, I always reply: it depends.

I would say that a fairly consistent national trend over recent years has been to chip away at the discovery protection of the incident report. And yes, any plaintiff counsel with experience knows that incident reports are ubiquitous in almost every healthcare setting, and they will often issue a request for product, subpoena duces tecum or the like to try and compel them to be produced.

I ask my staff to fill out the incident reports in a factual manner, with information that allows me to figure out why the incident happened, and I use them to figure out if are there are any lessons I can derive from this in order to change practices to reduce the risk of this incident happening again. Just as I instruct my staff about charting, I ask them to not write anything in the incident report that they would be embarrassed or chagrined to explain in front of the 12 nice people in the jury box or the administrative law judge or disciplinary panel at your license hearing.

Thank you! You answered my questions perfectly! Yet another reason to educate staff on the importance of complete, factual and objective charting. I work in a SNF and we still use narrative charting. Some nurses chart entries are less than stellar and more resemble an exercise in a creative writing class than a nursing note.

psu_213, BSN, RN

Specializes in Emergency, Telemetry, Transplant. Has 6 years experience.

Some nurses chart entries are less than stellar and more resemble an exercise in a creative writing class than a nursing note.

Yes, I see some of those notes too. Either that or they chart virtually nothing on some sort of an incident.

I don't know the legalities re: incident report, specifically if they can or cannot be evidence for a plaintiff's attorney in court if they are not mentioned in the actual chart. Either way, though, I keep mine short and sweet, and, in the incident report, refer the reader to my nursing note. I don't feel like typing out my assessment again in the incident report when it is all in my NN anyway.