Question about who is responsible for an incident report

Nurses General Nursing

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Ok so the other day my wife was working a 12 hour night shift with the first 4 hours on one unit and the following 8 hours on a different unit. She arrived on the second unit around d 11:15 after giving report to the relief on the first unit. During 11 and 11:15 there was a fall on the second unit before my wife had made it to the floor. The nurse who was still on that unit assessed the pt and removed them from the floor and reported it to my wife but did not do an incident report. My wife also did not do an incident report because she was not the nurse who saw the pt on the floor and assessed them. She did write a nursing note for her shift with vitals and follow up assessment.

Her employer is telling her that she is the one responsible for the incident report because it happened after 11 and that it's not their job to pay overtime to the previous nurse to stay and do it although my wife wasn't even on the floor yet when it happened. She was concerned about how this could be used in court against her and that it could be false documentation. Her employer does not care and actually yelled at her for bringing up these concerns. She talked to her supervisor, the ADON and the DON and they are all saying that it is her job and not the other nurse. This makes no sense to me.

At my hospital, the person who finds the pt on the floor is who does the incident report, even if it's a CNA. The nurse may fill out the parts pertaining to medication and dr. Notification and so forth, but the person who finds the pt is who describes the incident.

I know that incident reports are not part of the pt's chart but they can be used for litigation purposes. Am I right in thinking that her facility is a careless place? And are they wrong?

Specializes in ER.

The policies book should be quite clear on who fills out the incident report. I don't think it's politically helpful to your wife to point that out even if she is right, but it'll give her an idea of what kind of workplace she's taken on.

Specializes in Geriatrics, Dialysis.
It's not that I would expect it to end up in court, it's more a question about who should be responsible and if her filling out the details of the report could be considered false documentation.

1] It is pretty standard procedure to not ever mention an incident report in charting. This then opens the door for state and/or lawyers to gain access to not only that particular incident report, but all of them. Incident reports are actually the domain of the company and not part of a medical chart. So, unless somebody foolishly mentioned said incident report in the chart, it will not be part of any kind of court proceedings should it come to that.

2] While it's also pretty standard for the nurse witnessing the event to complete the paperwork that doesn't always happen. There is a big grey area...shift change. It's not unusual for the oncoming nurse to complete paperwork when a fall [or other incident] happens when both off-going and oncoming nurses are in report.

3] Incident reports often include information that isn't witnessed by anybody. Pretty often nobody was there to see the fall so all of the information in the report is either by direct observation of the events that were witnessed after the incident, objective findings per nursing assessment post-fall and subjective findings per interviewing the patient and the staff that initially discovered the situation. Any reported findings are simply prefaced with "per report by XYZ" and this makes it perfectly clear that the person actually filling out the report is not the person who witnessed these particular findings.

I am only using a fall as the example since it my experience that the majority of incident reports are fall related, though there can be any number of things that can trigger an incident report being filled out. Since these reports are facility generated and facility property policies and actual reports used will vary.

Specializes in critical care.

In my opinion, it IS the facility's job to keep the nurse on overtime to do the incident report, and your wife was not present for the fall therefore is completely unable to do an incident report. She can only report what she observes, which would be the follow up assessment. She has no way to know that what was reported to her was exactly how it happened. I wouldn't touch that incident report with a 10 foot pole.

Specializes in LTC/Rehab, Pediatric Home Care.
1] It is pretty standard procedure to not ever mention an incident report in charting. This then opens the door for state and/or lawyers to gain access to not only that particular incident report, but all of them. Incident reports are actually the domain of the company and not part of a medical chart. So, unless somebody foolishly mentioned said incident report in the chart, it will not be part of any kind of court proceedings should it come to that.

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.

Specializes in Emergency, Telemetry, Transplant.
Ok. I just wanted to make sure that they weren't trying to make her do something illegal.

No, it would not be illegal. She should simply state "Per report from Sarah Smith, RN, pt was observed on the floor at 2305 on 6/12/2015. See nurse's note by Sarah Smith, RN timed 2308 for details on the incident, pt. assessment and pt. VS."

That way, the incident it forwarded to risk (or whomever deals with these reports) and it is clear that is does not fall (no pun intended) on her.

Every place that I've worked at it's the person who found the patient on the floor who start the incident report. Now, I worked for one place that if the aide found the patient on the floor and a nurse was on duty, they were not to help the patient up but to radio the nurse for assessment. In this case, the nurse who came in saw exactly where the patient was went they fell and proceeded from there with assessing the patient to see if safe to get up or if EMS was necessary. Then, the nurse would fill out the report. If it happened overnight (no nurse) the aide would start the initial report with writing in what had happened and the nurse would then assess the patient for injuries that may not have been noted by the aide and complete the rest of the report, notifications, etc.

If it's change of shift, give report, and then finish your incident report. It should not be left for someone who wasn't there when a licensed nurse tended to the patient on the floor. We cannot document what we have not observed. If your wife is getting issues from management because they want to pinch pennies this badly (especially with a fall, which can result in a legal case if injured) then I would recommend finding a better facility to work for, just my suggestion.

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.

Specializes in Geriatrics, Dialysis.
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.

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

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.

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 ?

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*

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