Incident Reports

This offering expires in 2 years: Oct. 23, 2008

The goal of this continuing education offering is to provide nurses with current information on incident reporting. After you have completed reading this article, you will be able to:

1. Discuss the relationship of risk management and incident reporting.

2. Identify the critical elements of an incident report.

3. Describe perceptions of and impediments to incident report completion.

You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

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As most nurses are aware, healthcare facilities have long maintained risk management programs that require nurses to complete incident reports in accordance with the organization's established policy and procedure. While incident reports always have played an integral role in risk management programs, their utilization and importance has now been realized in patient safety programs. Since nurses are usually the "frontline" staff responsible for incident report completion, this nursing activity is evermore crucial to effective and safe patient care.

This article will discuss: 1) the role of the incident report in effective risk management, patient safety and quality of care; 2) who should complete the incident report; 3) what it should include; and 4) perceptions and impediments to incident report completion.

Note: This article focuses on those incident reports filed within a healthcare facility and not those reports that may be separately required under state law as part of a state's event reporting system.

Risk Management & Incident Reports

Risk management is a process designed to prevent adverse consequences and minimize adverse economic effects on an organization occasioned by accidental loss. The focus of risk management then is to prevent financial loss resulting from actual injury to patients, visitors, employees and medical staff, as well as from damage, theft or loss of property belonging to the healthcare organization.

Risk management involves insuring against financial loss and developing a systematic process to identify, evaluate, reduce or eliminate deviations from expected results. Over time, risk management has evolved to include evaluation and monitoring of clinical practice to recognize and prevent patient injury.

Incident reporting traditionally has involved documenting actual unexpected or unusual events retrospectively (i.e., after the harmful event has transpired). Data from the incident reports are then tracked for quality assurance and risk management purposes. Incident reports allow the detection of emerging trends or problems.

Patient Safety & Event Reporting

Medical errors and patient safety have received tremendous attention since the late 1990s and patient safety is now recognized as a separate discipline within the field of quality assurance. Many factors have contributed to patient safety's prominence, but there is little question that the 1999 Institute of Medicine report, "To Err is Human: Building a Safer Health System," was a major impetus.

JCAHO recognized and sought to address patient safety before the IOM report changed others' awareness of the problem. In 1996, JCAHO issued its sentinel event policy, which required accredited organizations to conduct root cause analyses of all serious adverse events and develop measures to reduce the likelihood of a recurrence of the sentinel event. JCAHO defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury or risk or the loss of a limb or function (sensory, motor, physiologic or intellectual) not previously present or requiring continued treatment or lifestyle change.

JCAHO expects accredited healthcare organizations will perform both root cause analyses of sentinel events and failure modes and effect analyses of "near misses." A near miss is an event that narrowly avoids harm. With the advent of the patient safety movement, healthcare providers now focus on near misses, and rightly so. Near misses statistically occur more often than actual adverse events.

Near misses represent opportunities for improving the health and safety practices within a healthcare facility. If the underlying hazards surrounding the near miss are quickly identified, remedied and widely communicated, the likelihood of the event recurring is greatly reduced or eliminated. Near misses are now an additional focus of the incident reporting process and represent another important reason for nurses to accurately and timely complete incident reports.

Impediments to Reporting

Most facilities outline for nurses the circumstances under which incident reports must be completed. However, for a variety of reasons, medical errors often are underreported.

First, nurses perceive that completing an incident report will lead to punitive disciplinary action from facility management or inappropriate disclosure to others. Many nurses also erroneously believe incident reports will be placed into their personnel records. While some managers may inappropriately use incident reporting in a punitive fashion, many facilities are recognizing patient safety requires a just culture where blame and shame are eliminated.

Second, nurses may believe the incident reporting process has little inherent value and fails to result in any constructive change. Often, the completion of the incident report is seen as additional unnecessary paperwork ultimately ignored by administration. As this article points out, the completion of an incident report is crucial to effective quality, safety and risk management.

Third, nurses may fear if they complete the incident report, they will be named in any legal action that results from the incident. While it may be true the incident report will come to light in a tort suit, completing the incident report does not make the nurse a target of a lawsuit.

Incident Reporting Process

Of course, when an event occurs, the nurse's first responsibility is to attend to the patient and minimize additional harm. Further steps usually are dictated by facility policy, but generally a physician and an immediate nursing supervisor should be notified. When and by whom any family members are notified also will be determined by facility policy, but disclosure should be encouraged.

The individual who discovers the error or who is directly involved in the event should complete the incident report. If nonclinical personnel discover the error, a clinical staff member should assist in the report's completion. Either way, the report should be completed in a timely manner, as close in real time to the event as possible. Memories fade and critical details can be lost if the report is not completed in a timely manner. Many facilities require the report to be completed within 24 hours for precisely this reason.

The actual incident report form often is developed internally by the facility. A good incident report will effectively collect information that can be used by risk management, quality assurance and patient safety committees to harvest important data.

To help ensure staff completes the report in a timely manner, the report should be concise, easy to use and practical. A checklist format with a narrative section is used most often. Essentially, the incident report should be like a good news story - who, what, when, where and why should be answered for the reader. Witnesses, contributing factors and any relevant clinical information should be included.

What Not to Do

The incident report is generally considered to be an administrative record of the facility, not part of the legal medical record. That is why the fact an incident report has been completed is not documented in the patient's medical record, nor a copy placed in the patient's medical record.

The incident report is not the place for speculation, editorializing or laying blame. The investigation of the root cause of an event is best left to individuals charged with making those conclusions for the facility - the risk manager, patient safety officer or quality assurance. Likewise, the medical record completed contemporaneously with the incident report should only contain factual, objective, descriptive documentation relative to the patient's condition and response to the incident.

Missing Data

The incident report is the foundation upon which any further quality improvement measures are taken in response to the incident. The goal of incident reporting, as stated previously, is to foster a better understanding of a facility's problem areas as they relate to safety. For that reason, failure to include crucial information or otherwise properly complete the incident report may impede further root cause analysis or failure modes and effect analysis. If incident reporting is not complete, reliable and accurate, it is nearly impossible to form valid conclusions.

Failure to accurately complete the incident report form could lead the incident to subsequently be misclassified and cause the level of investigation and follow-up inquiry by risk management to be less stringent than appropriate.

For example, suppose you are a nurse working in a skilled nursing facility. You find bruises on the thigh of a resident, and on the previous day the resident described to you an incident of rough handling by a staff member. You are too busy on your shift to provide a detailed account in the incident report that correlates your finding of the bruises with the specific complaint about rough handling made to you by the resident.

In this instance, the incident report does not adequately describe exactly how the injury may have occurred. Consequently, the injury could well be classified by risk management as an "injury of unknown origin," when in reality the injury really may be due to suspected abuse.

Failure to properly include all individuals involved in an incident also can impact the beneficial use of an incident report and create increased liability exposure. Imagine you find a patient on the floor of the hallway of your patient care unit. The patient complains of hip pain and a follow-up X-ray shows a fracture.

When you complete the incident report, you don't include the visitor on the unit who witnessed the fall. The result is that the fall seems to have gone unwitnessed. Some time later, the patient sues the hospital for damages resulting from the fall. The risk management team looks at the incident report that fails to list any witnesses. However, the patient is able to produce the testimony of this witness who states the fall occurred when the patient tripped over an object left in the hallway. Obviously, your facility is at a distinct disadvantage in defending itself against this claim.

Creating 'Just Culture'

One reason nurses often cite for failure to complete incident reports is the fear of reprisal or disciplinary action if the nurse reporter appears "culpable" as the cause of the incident. Incident reports are not are included in their employment and personnel files. To promote effective reporting and achieve quality care, facilities must adopt what is referred to as a "just culture." The just culture recognizes it is rare for any single nurse to be the cause of an incident of patient harm; instead, multiple systemic factors often combine to create the circumstance wherein harm may result. The just culture eliminates punishment of healthcare practitioners unless the employee can be found to have engaged in malicious, reckless or illegal behavior.

Rather than blaming and pointing fingers at the nurse involved in an incident, more facilities are looking "behind" the incident to determine other factors that served to create the harm, including orientation and training, staffing ratios, and other issues influencing patient safety and quality outcomes.

Another important point cited by nurses is the overall incident reporting process is perceived as having little or no value due to the lack of follow-up and feedback provided to the nurse on constructive change. As a result of the patient safety movement and improvements implemented by facilities, this should become a less relevant impediment.

Resource

Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Renee H. Martin is a registered nurse and attorney with Tsoules, Sweeney & Martin, LLC, Exton PA.




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