incident reporting_ nsl3.1(apr 2011)

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Incident reporting

Incident reporting is part of quality

improvement and safety

The key reason for reporting incidents is tolearn from them, and if possible, prevent their

repetition.


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Without a detailed

analysis of incidents

and near misses,

we may fail to

uncover problemsthat are potential

hazards to clients

and staff.


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Objectives State the purpose of filing an incident report

State 2 implications of the incident report

Accurately describe & record events/incidentsobjectively

Selectively include important components in theincident report

NSL 3.1 (April Semester 2011)

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Defensive Documentation Document charting in a healthcare institution

reflects the quality of care your client is

receiving. Careless, inaccurate or incomplete charting

allows opportunities for false claims in a lawsuit.

Good charting practice is the primary defensefor the institution and her staffs against liability.


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Fundamental Principles ChartingTimeliness of Entries

This prevent information from missing out andforgotten.

Pre

dating & Back

dating entries areconsidered unethical and illegal.

Permanency of Entries

Medical record are permanent documents.Use ink that does not smeared easily; thatensures legible photocopying (avoid red ink).


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Fundamental Principles ChartingAuthentication of Entries Each entry must be signed with name and designation of

staff clearly stated.

Nurses should never make an entry on behalf of anothercolleague.

Legibility

Illegible writing can potentially cause misunderstandingthat eventually causes client injury.

Misspelled works and poor grammar can potentiallychange the intended meaning hence causing

misunderstanding.

Use of Abbreviations

Abbreviation that is not approved or standardized in theinstitution can be misunderstood & confused by otherstaffs causing client injury. NSL 3.1 (April Semester 2011)

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Incidents

Seen as a serious situation in a healthcareinstitution

May be the result of clients action, nurses

action, doctors action or equipment failure.

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Purpose of Filing an Incident Report

Informs the hospital administration about aproblem (patient injuries, medication errors,and injuries to employees or visitors).

Monitor trends and implement measures toprevent similar incidents from happening by riskmanagement team.

Alert the administration and facilitys insurance

company to a potential claim.

Alert the need for further investigation

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Incident Report

Who file incident report? Only nurses who witnessed/is involved in the

incident

How many incident report should be filed?

Each witness should file a separate report for thesame incident

Who review the incident report?

Unit manager Attending doctor/s

Nursing administrators

Institutions lawyer

Insurance company

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Reporting Incidents

Incident reports are confidential.

These reports are filed separatelyNOT INthe clients case notes.

Submit form or electronic form to unitmanager.

Never indicate in the nursing report thatan incident report is filed.

Indicate only the findings and thetreatment rendered.

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Common incidents that requires

an incident report: Involved client Falls

Medication error

Discharged against

medical advice Erroneous procedure

performed

Client abscondment

Transfusing the wrongblood

Delay in treatmentcausing lifethreatening events

(cardiac arrest)

Involved staff

Needlestick injury

Any work-related

injuries

Involved staff, clientor family members

Clientstaffdispute (potentiallawsuit)

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Guidelines for completing the report

Include State the names of any persons involved and

witnesses

State only facts about what happened

State the consequences to the person involved

State additional relevant facts (observations), andyour immediate actions

Exclude

Opinions, conclusions, assumptions Personal thoughts on who or what might have

caused the incident

Suggestions for preventing a similar incident in thefuture

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Guidelines for completing the report

Relevant parameters from regular charts maybe used

Names (nurses / doctors / clients) must bespelled in full

Avoid abbreviations if possible; use institutionapproved abbreviation only

Use Military Time format to indicate time ofoccurrence (see next slide)it is unambiguous

Date format: ddmm

yyyy

Quote clients words accurately if needed;

patient stated, .

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References McCann, J.A.S. (2003). Complete guide to

documentation. Philadelphia: LippincottWilliams & Wilkins

Springhouse. (2006). Charting madeincredibly easy. Philadelphia: Lippincott

Williams & Wilkins

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incident reporting_ nsl3.1(apr 2011)

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