Should this have been an incident report?

[emoening]

I wanted to get everyone's take on this.

Yesterday at work I got out of report at 7:30am and began to make my rounds on my 6 patients. At 8:15 one of my patient's physicians called me and said he was taking my patient to the OR in 45 minutes for a urinary stent and to have him ready. This entailed printing out his OR packet, getting the consent signed, pre-op checklist, and giving him the CHG bath. He said the procedure would take about an hour and he would have him back by about 10:30. I was just finished wiping him down with the CHG wipes when the transporter arrived to come get the patient. About 2 hours later my patient had not returned, and I was told by the house supervisor that something had happened in the OR and the patient would be going to ICU after the procedure.

Later that afternoon when the patient had arrived on the ICU, the nurse taking him over called me, I was assuming to get report. Instead, she chewed me out over the phone, and told me she was filing an incident report against me, because she received the patient and chart from the OR and my charting had not been done for the day. I told her that the patient was taken from me at 9am, and I assumed he would be back to me by 10:30, when I would catch up on my charting. She told me, that is not an excuse, and it is an incident report if you do any charting after the fact, that you have to chart as something is happening. I told her I would be more than happy to come down to the ICU and do my charting for the 2 hours I had the patient, but there is no way I could have known he would end up in the ICU and wouldn't be able to finish my charting when he came back. She said fine, but that she would still be filing the report.

I told my charge nurse about what happened and asked if I was in the wrong, or what I should have done differently. She said no I was not in the wrong, and that I couldn't have done anything different. She also said we are not expected to chart everything immediately, that is literally impossible. On my floor, it is the norm rather than the exception to start your charting around noon or so, once you've assessed all your patients, done all your AM meds, taken off MD orders, etc.

So my questions are: do you think this was a ligitimate incedent report? And how many of you do your charting immediately? Or do you actually "do" everything first, and then sit down and chart later?

[AggieNurse99, BSN, RN]

To the OP: an incident report should be completed any time "risk management" should investigate a process or procedure or if hospital policy is not followed. A problem I find (as a floor nurse) is that my coworkers seem to think a "near miss" doesn't need to be written up - it does! The process leading to the near miss or problem needs to be investigated - i.e. pt admitted on day shift. MAR handwritten (including weekly meds) by nurse, including admin times. Night shift follows MAR. Following Day shift, preprinted MAR is completely off on med times, weekly med should have been given previous day, multiple antibiotics off etc. Night nurse blows a gasket when Day nurse writes med report. Not the night nurse's fault, the process needs work. You should write an incident report yourself, as you most likely missed meds and AM care for your other pts while seeing to the surgeon's last minute orders. AND the consent issue.