Incident Report Systems: Documenting Adverse Patient Events - Case Study

Introduction

Incident report systems differ in functionality, design, and maintenance reports of patient-safety related events that are documented by nurses, doctors, and hospital staff. The reports indicate all the adverse scenarios, "near misses" as well as situations that can result in potential harm to the patients (Department of Health and Human Services, 2012 p. 1-2). When completing an incident report, the staff usually describes the situation when they first arrived. This narrative is usually given in first-person accounts. Any second-hand information is typically put in quotation marks, regardless of whether the comment was from a colleague, patient, or visitor. Additionally, the staff includes full names of all the parties involved, such as any eyewitnesses, and information that involves how or if they were affected. Finally, the staff also adds any relevant information, such as immediate responses such as calling for help, bandaging wounds, and assisting with showers. The staff is also mandated to include statements made by patients that further clarify their situations, such as things he noticed or failed to notice. The reports are submitted manually in writing.

Is your time best spent reading someone else’s essay? Get a 100% original essay FROM A CERTIFIED WRITER!

Save 25%

Does your facility support a robust "reporting culture"? Discuss your response.

Yes. Our facility expects all check-ups performed by physicians as well as nursing staff to be accompanied by accurate and factual reporting. All nurses are expected to hand in their reports to the senior management for analysis and comparison. Furthermore, they enforce this culture; nurses are routinely rotated in order to ensure that accurate reporting and recording is done on all patients. Moreover, our facility fosters a team approach whereby every member is aware of the vital role that they have to play. For instance, the nurses and junior doctors are taught how to complete the reports by the senior supervisors before taking on the tasks while under supervision in order to reduce the chances of error.

The Just Culture

A just culture can be defined as a fair and reliable environment that supports transparency, open communication, information sharing, voluntary error reporting as well as the willingness to do the right thing (Paradiso & Sweeney, 2017 p. 8). According to Boysen (2013), a just culture facilitates stability for the need for an open and honest reporting with the result of a quality learning environment and culture (par 15). The employees should distinguish that they are more likely to receive fair treatment when they report safety, near misses, or even incidents as all employees are held responsible for the quality of their decisions. Therefore, for a just culture to be productive, it has to focus on systems design as well as management of behavioral choices of the staff instead of focusing on the outcomes and errors.

Identification of the Problem in the Case Study

The main error in the case study is an error in reporting. The first error occurred when the nurse receiving the patient on the unit failed to document the patient's history of MRSA. The new nurse recorded additional statements from the patient, which claimed that the previous nurse had ignored the complaint that the patient had a "boil" under her arm. Furthermore, the error of reporting is also indicated where the nurse recorded an open wound, which was approximately two weeks old, as stated by the patient. Furthermore, the nurse also indicated a circular area of redness that should have been included in the previous nurse's report. The error first occurred when the patient was being received at the acute care from the emergency room. Before the exchange, the patient's records were documented accurately with the inclusion of her history of MRSA. However, the nurse receiving the patient failed to make proper records of the patient's details.

Poor reporting in health institutions can be as a result of various problems. For instance, the nurse may have been fatigued that he was unable to record correctly. The nurse may have had numerous patients to tend to; thus, the need to rush through the activities results in poor reporting as well as the recording of information. Multiple nursing actions, lack of a reward system, or even lack of continuous monitoring and evaluation may have contributed to poor recording and documentation by nurses. Mutshatshi et al. (2018) note that there are many forms that the nurses need to fill, which are time-consuming and laborious. As a result, the nurses may experience the time factor of time as a challenge in regards to the duties they have to perform, resulting in a poor recording.

Impact of the Problem

Failure to indicate all the pointers is detrimental to the patient's health as the nurse did not indicate the patient's history of MRSA. MRSA requires patient isolation as well as individual attention. Furthermore, the failure of the first nurse to record the patient's wounds would have made the institution liable for a lawsuit if the error was not discovered on time. Incident reports are essential documents that are used to ensure the safety of patients through enhanced activities. As a result, the institution, as well as the staff, are accountable for their actions. Even though the just culture encourages employees to do the right thing, the employee is still liable for the decisions and choices made. The implication for the employee is that the situation would have escalated to a potentially disastrous event if the error had not been identified, such as the worsening and potential death or amputation of the patient due to malpractice. However, the inability of the employee to keep accurate records will result in a reduction of duties, as well as a re-evaluation of records kept by the nurse.

Findings and Root Cause

The findings from the case study indicate that the error of poor reporting as a result of the nurse failing to record the patient's previous history with a severe illness. The nurse also did not take into consideration the statement of the patient, which would have helped to shed light on her condition, nor did she record everything that she saw, such as the condition of the patient's wound. However, the nurse took part in routine responses such as cleaning and dressing the patient's wound.

The findings suggest that the leading cause of this error is the lack of sufficient time to document patient data properly. Nurses at any institution have multiple tasks to fulfill, and many patients to offer services. As a result, the nurse may have lacked sufficient time to document the information as he had to rush to see the other patients or perform other tasks before the end of the day. Therefore, as a recommendation, the appropriate response would be to continuously monitor and evaluate the nurse to ensure that the patient's report is recorded accurately and factually.

Recommendations to Prevent Further Incidents From Occurring

To prevent future incidents from occurring, the institutions should ensure that they create a list of potentially reportable events. This list will help the staff to ensure that they have recorded all the essential notes. Furthermore, the institutions should also ensure that they educate the staff on the potential harm that can occur due to poor incident reporting.

References

Boysen, P. G. (2013). Just Culture: A Foundation for Balanced Accountability and Patient Safety. Ochsner Journal, 13(3), 400-406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/

Mutshatshi, T. E., Mothiba, T. M., Mamogobo, P. M., & Mbombi, M. O. (2018). Record-keeping: Challenges experienced by nurses in selected public hospitals. Curationis, 41(1). https://doi.org/10.4102/curationis.v41i1.1931

Paradiso, L. A., & Sweeney, N. (2017, May 5). The Relationship Between Just Culture, Trust, and Patient Safety. CUNY Academic Works. https://academicworks.cuny.edu/cgi/viewcontent.cgi?article=1163&context=ny_pubs

The United States. Department of Health and Human Services. Office of Inspector General. (2012). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.