September 02, 2015 | | Comments 0
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Incident Reports: What You Need to Know (Part Two)

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 a popular post full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2Yesterday we looked at the purpose of the incident report and the value of documenting facts as well as the patient’s responses to care in the nursing progress notes (see Incident Reports: Part One). Today we’ll look at eight risk reduction recommendations you should follow to limit the number of incidents you face. We’ll also give you a check list of tips for writing incident reports should adverse events occur. (I’ll make the checklist available as a PDF download in a few days, so check back for the link.)

RISK REDUCTION RECOMMENDATIONS FOR NURSE MANAGERS

  1. Be sure that everyone is clear as to who is managing the patient. This is especially critical in complicated cases with numerous consults. One of the major factors in adverse events is fragmentation or lack of clear communication between providers. Therefore, use the medical record as a communication tool for all providers and encourage your staff to read notes from other providers and disciplines.
  2. Be sure staff understand and utilize the chain of command when necessary. They are considered patient advocates and must speak on behalf of the patient to ensure quality patient care. Documentation of the chain of command process should be factual and blameless.
  3. Advise your staff never to create notes at home concerning the event. They should not discuss the event with other care providers without having someone from risk management present, unless the discussion is in a quality-review process or in the presence of the facility’s attorney.
  4. If an adverse event occurs, the staff must know that attention to patient needs is first and foremost. If a patient is injured, nursing and medical interventions take precedence over everything else.
  5. Follow the organization’s policy on medical-event disclosure. It is important that staff understand who is designated to inform the patient/family. Documentation should include who was present during the discussion, what information was discussed, and all of the patient/family responses.
  6. Ensure that the patient/family receives compassionate care and that everyone involved maintains a professional relationship.
  7. If an adverse event occurs, contact the risk manager. Discuss the case discretely, because conversations are not protected under a quality statute or attorney-client privilege, and therefore may be discoverable.
  8. Work with the risk manager. The risk manager can help you and your staff promote patient safety and proactive strategies to avoid injuries.

TIPS FOR WRITING AN INCIDENT REPORT

In many states, the incident report can be reviewed by the plaintiff’s attorney. Therefore, it is important that you and your staff keep in mind that others may read it. Use the following check list of what to do and what not to do to make sure that you fill them out correctly.

incident report tips

About the author: Patricia A. Duclos-Miller, MS, RN, CNA, BC, is a full-time associate professor in nursing at Capital Community College in Hartford, CT. During her 30-plus years in nursing, Duclos-Miller has served in a variety of roles, including staff nurse in the specialties of medical/surgical nursing, obstetrical nursing, and neonatal intensive care. She is a recognized speaker on contemporary nursing topics such as quality, team building, and documentation issues. She is the author of Managing Documentation Risk: A Guide for Nurse Managers, Second Edition.

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

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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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