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Some Tips on Incident Reporting

Tuesday February 20, 2001
Trudy Tappan, RN
Trudy Tappan, RN
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It's unfortunate when medication errors wind up on the front page of major newspapers, but the truth is that everybody makes mistakes. From time to time, even the best nurses do. But rather than throw in the towel, there's always something the nursing profession can do to bring down the error rate. One strategy is the use of the incident report, a tool for tracking problems and protecting institutional assets as well as shining a light in some dark corners.
Incident reporting in many settings is mandatory, and RNs in the Sunshine State don't have a choice about using them. Florida Statute 395.0197 requires every hospital and ambulatory surgery center to adopt an incident reporting system. What's more, staff in these facilities must report not only serious injuries on their premises, but ones they hear about in other healthcare settings, such as nursing homes, assisted living facilities, home health agencies, and physician and dental offices.
Florida Statute 641.55 dictates similar reporting of patient injuries by health plans. In 2000, according to Rule 64B8-9.001 of the Florida Board of Medicine, physician office staff joined the list of those required to report serious incidents.
So whether you're a seasoned nurse who has filled out lots of incident reports or a new grad who has never made an error, everyone benefits from a refresher on this important risk management tool.
Who Does the Report, and When?
In Florida, incident reports aren't limited to professional staff. Anyone can fill them out, and the person who discovers the error - even if he or she didn't commit or contribute to it - is the most likely candidate. Let's say your shift starts at 11 PM. While making rounds, you discover an elderly woman on the floor of her room. The bed rails are up. Judging from her appearance, you know she most likely fell during the previous shift. You're the first on the scene, so you write the report, and the hospital risk manager signs it.
Florida Statute 395.0197 requires that a licensed healthcare risk manager or the risk manager designee examine and endorse all incident reports in hospitals and ambulatory surgery centers. This review must occur within three days of the reported event. Others at the facility - the nurse manager, for example, or the supervisor - may assist in filling out incident reports, help analyze cause and effect, and develop a corrective plan.
Depending on the seriousness of reported incidents or trends, the facility's medical director and members of the governing board may be involved in an investigation. Since the buck stops with the board, it may decide to seek legal advice. The report should be completed as soon as possible after discovery of the incident. This minimizes the chance that personnel will forget the fine points. So, if a mistake occurs at the
end of the day or shift, can you put off writing it up until the next day? You can - but you'd
better not.
What's Needed in a Report?
Experienced RNs may know their institution's reporting policy by heart. New nurses or those that desire extra support should consult the facility's policy and procedure as they write the report. Other items to have on hand are:
∑ The current form your facility uses.
∑ The medical record for noting demographic and/or patient-specific data.
∑ ICD-9 and CPT-4 books to record diagnoses and any injuries resulting from the incident.
Be objective and stick to the facts - put aside opinions, assumptions, and hearsay. Remember that an incident report provides a detailed, accurate description of the circumstances. Use the five Ws as a guide:
∑ Where? Describe the incident's location.
∑ When? Give the date and time of the incident.
∑ Who? Tell who did what to whom and who witnessed the incident.
∑ What? Describe what happened in enough detail that your memory is easily refreshed should a lawsuit be brought years later.
∑ Why? Did equipment fail? Did someone fail to perform a certain task? If so, then say so.
What Reports Does Florida Require?
Florida's Agency for Health Care Administration (AHCA) requires reports within 24 hours for serious incidents and also Code 15s - that is, reports submitted within 15 days. The following are considered serious incidents:
∑ Unexpected death over which the practitioner had some control
∑ Wrong-site surgery
∑ Wrong-patient surgery
∑ Wrong surgical procedure
∑ Surgery that's medically unnecessary and not based on diagnostic or risk factors
∑ Unplanned surgery to remove foreign objects following a procedure
∑ Brain or spinal damage to a patient
∑ Unplanned surgery for repair of an injury or damage from previous surgery. According to AHCA, this type of incident may account for up to 350 Code 15 reports per year at hospitals and surgicenters between 1997 and 1999.
The Code 15 report asks for a number of particulars including the identity of the patient, the type of incident, and license numbers of physicians and nurses, plus Social Security numbers of nonlicensed persons involved.
Florida also requires analysis and corrective action to prevent incident recurrence. In providing this, answer the following questions:
∑ Why did this incident happen?
∑ What were the contributing factors?
∑ How can it be prevented in the future?
Like it or not, the incident report is a risk-management tool we all need to use properly. The information it contains is a valuable resource. We can all learn from our mistakes, and our patients will surely benefit.