How often do nursing incidents go unreported?

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How often do hospital incidents go unreported for fear of retribution?

Have you been late in passing meds, hanging an antibiotic mini or even delivering patient care in a timely fashion? Unfortunately, all of these can be classified as reportable incidents.

At times, we all have fallen behind at work. Do we want to risk our jobs by filling out the necessary reports and documenting our inadequacies?

Reporting an incident involves a lot of paperwork and time. Is it all worth it? Will administration use these reports against us? It can be hard to know what to do.

This is when you need to turn to administration and use your voice. Ask if incident reports that are reflective of short staffing and heavy patient assignments are used as tools to correct staffing problems or will be used as retribution against the reporting nurse. If the answer to your question is no, then by all means, go ahead and write that incident report. If the answer is yes, you may have to decide which battles to fight.

It can be difficult to report an incident that you feel you could have prevented if the stars and moon were aligned. Just remember, it’s always best to cover your back and do what protects you and your patient’s right to a safe hospital stay. You may even create change in your facility.

When to file an incident report:

  • Patient falls/injuries
  • Patient neglect or abuse
  • Late or delayed patient care
  • Late medication administration
  • Faulty equipment
  • Nurse/staff falls or injuries
  • Nurse/staff physical abuse

Always contact your nursing supervisor for any incident that may be an injury, safety or abuse issue.

If this was a patient-involved incident, here are some tips on what to write in the patient’s chart:

  • Date and time of incident
  • Who found the patient and how
  • Was he/she in bed, a chair or on the floor?
  • Vital signs
  • Head-to-toe assessment (yes, again!—this may be a new diagnosis)
  • To whom it was reported
  • Treatment, if necessary
  • If this was a fall, how you returned the patient to the bed or chair
  • How many staff were involved in the transition
  • How you will prevent the incident from happening again (the patient was placed on fall precautions, the patient was moved closer to the nurses’ station, etc.)
  • A one-hour reassessment of the patient, if that is hospital policy

If this is a nurse-involved incident, notify the charge nurse or nursing supervisor and fill out an incident report. If this injury requires immediate medical treatment, go to your closest emergency department and then fill out an incident report.

If the incident happened because of faulty equipment and there was an injury, contact your charge nurse or nursing supervisor. Contact your biomedical personnel to remove the equipment, document the findings and treatment in the patient’s chart and file an incident report. Never use faulty equipment—it may harm you and/or your patient.

If this is a staffing-related issue, contact your nurse manager. If nothing happens, go up the chain of command and notify each level as to what your complaint is until your voice is heard. Always file an incident report when you are late in passing medications or delaying patient care due to large patient assignments.

Stick to the facts. Never exaggerate on an incident report. Always report what you saw, who was involved and how you dealt with it.

Candace Finch, BSN, RN, is an orthopedic nurse at Upstate University Hospital Community Campus in Syracuse, N.Y. A new empty nester, she finally has time to do the things she’s put off for years and thinks change is always good!

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