Should I have made an incident report?

[Kharma711]

So, just left a crazy shift in which a patient tried to bleed out on me... I had been told in report that the patient had had an IV in her right shoulder that had become dislodged and bled quite a bit. Since the patient was on a heparin drip, I didn't think much of it...

Fast forward 3 hours:

NG had become dislodged and I had to push it back to the appropriate place. The patient struggled during the procedure and I noticed new bleeding at the shoulder site. I remove the haphazard dressing to find bright red blood pulsing out of a small hole in her shoulder.

I attempted applying pressure and soon saw blood welling between the fingers of my gloves and called for the charge nurse. CN pulled back the gauze I was holding and quite literally got sprayed with blood O_O

So I call the resident and she comes to the bedside... long story short it took almost 60 minutes of pressure to stop the bleeding and a consult to vascular surgery because we thought we may need to stitch the shallow artery to stop bleeding.

Resident from vascular surgery said the IV had to have been in an artery because there was no signs of damage from the dislodgement, just a small hole from the 20g needle/catheter.

I of course wrote a long note detailing my objective findings and actions... I just wonder if I should have filled out an incident report too... thoughts??

[mercurysmom]

I would. Actually, I don't think I'd be able to sleep without going back in and re-reading my documentation to add every single detail in the timeline, and then wrote up an incident report. I'm a little neurotic about documentation, so YMMV.

[AJJKRN]

Highly probable that this was incident report worthy, when in doubt, always rule out a pulse!

[Been there,done that, ASN, RN]

Somebody started an "IV" in an artery That "somebody" needs to know it.

[Kharma711]

I'd also like to add that the IV being in an artery was documented by the resident in her note. I stayed objective and didn't even state it was in an artery but stuck with "pulsating, bright red blood noted" and documented actions taken on the patient's behalf, who was there, what was done, etc.

[RiskManager]

The RiskManager would like to see an incident report on this so appropriate followup can be done.

[VivaLasViejas, ASN, RN]

My rule was always, if I had to question whether or not to write an incident report...I wrote an incident report.

[RiskManager]

My rule was always, if I had to question whether or not to write an incident report...I wrote an incident report.

I tell my people something similar: if you are wondering if you should talk to the risk manager about something, you probably should.