September 01, 2015 | | Comments 0
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Incident Reports: What You Need to Know (Part One)

Incidents reports are a pain to fill out, but vital for documenting what happened and for protecting yourself and your staff. This week, we’re republishing installments of a popular post chock full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2If you and your staff think that incident reports are more trouble than they’re worth, you could not be more wrong.

We work in high-stress, fast-paced environments. It is your responsibility as a member of the nursing management team to understand the importance of incident reports, to ensure that your staff completes them, and to investigate incidents to avoid any further occurrences. Your investigation will also provide possible defense if during your investigation you identify a system failure and take the necessary corrective action(s).

The purpose of the incident report is to refresh the memories of both the nurse manager/supervisor and the staff nurse. While the clinical record is patient-focused, the incident report is incident-focused. The benefit to you and your staff is that the incident report will help you and the persons involved remember what happened even if years have passed since it occurred.

The incident report is a risk-management document that helps with rapid response or review of potentially faulty systems. A valuable tool for the hospital risk manager, the incident report can assist in identifying liability. In addition, the incident report provides the risk manager with the information needed to process restitution, if appropriate.

Documenting incidents in the medical record

When documenting an incident in nursing progress notes, give a factual account of the incident, including treatment and any follow-up care that was provided. Document the patient’s response to the care. Doing so shows that the patient was closely monitored after the incident and that the patient received appropriate care.

If the patient or family stated something about their role in the incident, be sure to include it not only in the incident report, but also in the progress note. For example, if the patient stated, “I know you told me to ring the bell, but I thought I could do it alone,” the defense attorney may be able to use the quote to prove that the patient contributed to the negligence. In this situation, the patient would be considered guilty of contributory or comparative negligence.

Tomorrow: Risk reduction recommendations for nurse managers and a tip sheet for writing up incident reports. See Incident Reports (Part Two).

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Filed Under: case reviewInfection controlLegal issuesNursing documentationNursing professional standardsPatient outcomesQuality of care

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About the Author: Claudette Moore is an acquisitions editor at HCPro, focusing primarily on nursing topics. She is always looking for new books that will create a better workplace for nurses and their managers, so contact her if you would like to publish with HCPro.

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