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rotect|ng yourse|f from ma|pract|ce c|a|ms

lssue uaLe lebruary 2007 vol 2 num 2


AuLhors ueanna L 8elslng hu A8n8C and aLrlcla n Allen MSn A8n8C

Pave you ever been called Lo glve a deposlLlon for a lawsulL? uo you wonder whaL lL would be llke Lo be
sued for malpracLlce? WanL Lo know how Lo reduce your chance of belng named ln a malpracLlce sulL?
Lvery day nurses analyze facLs and clrcumsLances on a casebycase basls and Lhen acL on Lhese
analyses lncreaslngly we're belng held accounLable for Lhese nurslng [udgmenLsand Lhe ouLcomes
LhaL ensue oor [udgmenL can seL Lhe sLage for a paLlenL ln[ury LhaL leads Lo a malpracLlce clalm
8elng named ln a malpracLlce sulL ls LraumaLlc Aslde from Lhe poLenLlal flnanclal devasLaLlon lL can
wreak emoLlonal havoc and sLrlke a faLal blow Lo your selfconfldence and selfesLeem 1hls arLlcle can
help you avold belng sued for malpracLlce ln Lhe flrsL placeand Lells you whaL Lo do lf you're sued or
called on Lo glve a deposlLlon 1he advlce and guldellnes we presenL are based on Lrends ln nurslng
malpracLlce sulLs as well as our experlence as legal nurseconsulLanLs who've revlewed and LesLlfled ln
malpracLlce sulLs lnvolvlng healLhcare professlonals

Def|n|ng ma|pract|ce
MalpracLlce ls negllgence mlsconducL or breach of duLy by a professlonal person LhaL resulLs ln ln[ury
or damage Lo a paLlenL ln mosL cases lL lncludes fallure Lo meeL a sLandard of care or fallure Lo dellver
care LhaL a reasonably prudenL nurse would dellver ln a slmllar slLuaLlon

SLandards of care and professlonal pracLlce
SLandards may orlglnaLe from several sources
- SLandards of careLhe care a paLlenL should expecL Lo recelve under slmllar clrcumsLancesare based
on Lhe professlonal llLeraLure (LexL and [ournals) proLocols and experL oplnlons
- SLandards of nurslng pracLlce derlve from faclllLy pollcles and procedures [ob descrlpLlons
professlonal sLandards and scopes of pracLlce (such as Lhose of Lhe Amerlcan nurses AssoclaLlon or Lhe
Amerlcan AssoclaLlon of CrlLlcalCare nurses) sLaLe nurse pracLlce acLs and experL nurses who provlde
lnformaLlon on whaL ls reasonable careful and prudenL care
Many lawsulLs don'L come Lo frulLlon for years afLer Lhe lncldenL so Lhe courL wlll Lry Lo esLabllsh Lhe
sLandards of care and pracLlce aL Lhe Llme of Lhe lncldenL ln quesLlon
LlemenLs of a malpracLlce sulL
1o prove malpracLlce Lhe plalnLlff (Lhe parLy who lnlLlaLed Lhe complalnL) musL prove all of Lhe
followlng
- 1he nurse had a duLy Lo Lhe paLlenL 8y Laklng on Lhe care of a paLlenL Lhe nurse assumes a legal duLy
- 1he nurse breached LhaL duLy lf Lhe Lhree oLher malpracLlce elemenLs are presenL Lhe nurse may be
consldered negllgenL lf she breached her duLy Lo Lhe paLlenL 1o esLabllsh breach of duLy Lhe sLandard
of care musL be known
- A paLlenL ln[ury occurred 1he nurse's fallure Lo carry ouL a professlonal duLy caused paLlenL ln[ury no
ln[ury means no malpracLlceeven lf Lhe Lhree oLher malpracLlce elemenLs are presenL Powever noL
all paLlenL ln[urles necessarlly lnvolve malpracLlce
- A causal relaLlonshlp exlsLs beLween breach of duLy and paLlenL ln[ury 1he nurse's devlaLlon from Lhe
sLandard of care could reasonably have caused Lhe paLlenL's ln[ury
MosL common malpracLlce clalms agalnsL nurses
Cver Lhe years experLs have analyzed nurslng malpracLlce sulLs Lo deLermlne Lhe mosL common lssues
lnvolved MosL malpracLlce clalms agalnsL nurses cenLer on one of Lhe slx causes descrlbed below

a||ure to fo||ow standards of care
SLandards of care apply Lo numerous paLlenLfocused or nursefocused acLlons some may change from
year Lo year or even monLh Lo monLh Lxamples we've seen ln our work lnclude
- fallure Lo lnsLlLuLe a fall proLocol
- fallure Lo follow Lhe proper procedure for a speclflc sklll (such as glvlng medlcaLlons or lnserLlng a
nasogasLrlc Lube)
- fallure Lo apply anLlLhrombosls sLocklngs

a||ure to use equ|pment |n a respons|b|e manner
lallure Lo use equlpmenL responslbly may seem llke an obvlous breach buL lL's noL always so clear cuL
lor lnsLance you could flnd yourself ln legal [eopardy lf you rlg equlpmenL for a use oLher Lhan whaL Lhe
manufacLurer lnLended Cr you may declde Lo use equlpmenL you aren'L compleLely famlllar wlLh or
haven'L been adequaLely Lralned Lo use lf Lhe equlpmenL mlsuse harms Lhe paLlenL you're ln legal
[eopardy
a||ure to commun|cate
An elemenL ln mosL malpracLlce sulLs poor communlcaLlon may exlsL beLween a nurse and a physlclan
a nurse and oLher healLhcare provlders (lncludlng Lhose Lo whom she has delegaLed a Lask) or a nurse
and paLlenL lor lnsLance a nurse mlghL fall Lo
- communlcaLe all perLlnenL paLlenL daLa Lo Lhe physlclan
- provlde all relevanL dlscharge lnformaLlon Lo Lhe paLlenL
- communlcaLe lmporLanL assessmenL flndlngs Lo Lhe nurse for Lhe oncomlng shlfL
ln some cases fallure Lo communlcaLe can cause or conLrlbuLe Lo fallure Lo rescue (fallure Lo acL on a
paLlenL condlLlon resulLlng ln a code or a paLlenL's deaLh)
8ecause many conversaLlons aren'L documenLed fallure Lo communlcaLe can be dlfflculL Lo sorL ouL
durlng Lhe dlscovery process whlch occurs when boLh Lhe plalnLlff and defendanL's sldes gaLher more
evldence and Lake sLaLemenLs from Lhose lnvolved ln Lhe case 1o proLecL yourself documenL all
conversaLlons relaLed Lo paLlenL care normally you'd documenL ln Lhe paLlenL's charL buL lf a
dlsagreemenL abouL care arlses LhaL documenLaLlon should go Lhrough Lhe approprlaLe chaln of
command and reporLlng sysLem ln your faclllLynever ln Lhe paLlenL's charL

a||ure to document
ln Lhe eyes of Lhe courL lf someLhlng wasn'L documenLed lL wasn'L done ?our physlcal assessmenL may
reveal crackles of new onseL buL lf you don'L documenL Lhls flndlng oLher healLhcare provlders lack Lhe
lnformaLlon Lhey need Lo formulaLe an approprlaLe plan of care for Lhe paLlenL
Lack of documenLaLlon also can resulL ln a nurslng lnLervenLlon belng done Lwlce Say you admlnlsLer a
medlcaLlon dose buL fall Lo documenL Lhls acLlon and Lhen a colleague admlnlsLers Lhe same dose ?our
fallure Lo documenL could place Lhe paLlenL aL rlsk for ln[ury from an excesslve dose So be sure Lo
documenL all paLlenL lnformaLlon evaluaLlon flndlngs and lnLervenLlons 1hls noL only promoLes
conLlnulLy of care lL also helps subsLanLlaLe your care from a legal sLandpolnL

a||ure to assess and mon|tor
ueLermlnlng Lhe frequency of paLlenL assessmenL and monlLorlng ls a nurslng [udgmenL SomeLlmes a
faclllLy's pollcy or wrlLLen sLandard speclfles how ofLen Lo perform paLlenL assessmenL buL Lhls ls more
Lhe excepLlon Lhan Lhe rule
ln mosL cases LhaL lnvolve fallure Lo assess and monlLor nurslng experL oplnlons are crlLlcaland Lhese
oplnlons hlnge on Lhe sLandard of whaL a reasonably careful (or ordlnary) and prudenL nurse would do
ln a slmllar slLuaLlon lor lnsLance lf your paLlenL has a hearL raLe of 160 beaLs/mlnuLe how long should
you walL before checklng Lhe hearL raLe agaln? Should you check oLher vlLal slgns along wlLh Lhe hearL
raLe? WhaL oLher assessmenLs should you perform Lo Lry Lo deLermlne Lhe cause or effecL of Lhe rapld
raLe? All of Lhese are nurslng [udgmenLs you musL make based on your experlence Lralnlng and
undersLandlng of nurslng care
8ememberslmply followlng unlL proLocol or a physlclan's order Lo assess and obLaln vlLal slgns every 4
hours lsn'L enough lf Lhe paLlenL's condlLlon warranLs more frequenL assessmenL and monlLorlng
you're responslble for provldlng LhaL care reporLlng abnormallLles Lo Lhe aLLendlng physlclan or
advanced pracLlce nurse and documenLlng your flndlngs

a||ure to act as pat|ent advocate
lallure Lo acL as paLlenL advocaLe ls an lncreaslngly common elemenL ln malpracLlce sulLs lrequenLly
paLlenL advocacy relaLes Lo challenglng physlclan orders hyslclan challenges may lnvolve medlcaLlons
resplraLory managemenL dlscharge declslons and many oLher aspecLs of paLlenL care lL may also
lnvolve a requesL LhaL Lhe paLlenL be moved Lo a dlfferenL unlL or even a dlfferenL faclllLy Lo recelve
opLlmal care
lf you Lhlnk a physlclan's order could harm your paLlenL flrsL dlscuss Lhe slLuaLlon wlLh Lhe physlclan lf
Lhls doesn'L resolve your concern acLlvaLe Lhe chaln of command wlLhln your faclllLy's nurslng hlerarchy
1he chaln usually sLarLs wlLh Lhe charge nurse or unlL manager
nurses Lyplcally prlde Lhemselves on belng paLlenL advocaLes and on belng Lhe lasL safeLy check 8uL
sadly physlclan lnLlmldaLlon or unsupporLlve managemenL may prevenL full advocacy efforLs by nurses

now de|egat|on can |ead to ma|pract|ce c|a|ms
ln an efforL Lo conLaln cosLs and cope wlLh nurslng shorLages many hosplLals and healLh malnLenance
organlzaLlons requlre reglsLered nurses (8ns) Lo delegaLe cerLaln Lasks Lo llcensed pracLlcal nurses
(Lns) llcensed vocaLlonal nurses (Lvns) or unllcensed asslsLlve personnel (uA) 8uL delegaLlon can
puL you ln legal [eopardy lf you delegaLe a Lask lmproperly you may be sub[ecL Lo a malpracLlce sulL
SLaLe nurse pracLlce acLs and boards of nurslng govern Lask delegaLlon 1o properly delegaLe you musL
analyze Lhe complexlLy of Lhe Lask Lo be performed and assess paLlenL aculLy Lo deLermlne whaL Lype of
nurslng care Lhe paLlenL needs 1hen you musL assess Lhe ablllLles and knowledge of Lhe avallable Lns
Lvns and uA Lo deLermlne whlch person can besL provlde Lhe requlred care
When delegaLlng a Lask always be speclflc and use measurableLerms Lo descrlbe Lhe Lask keep ln mlnd
LhaL you may noL delegaLe a Lask (excepL Lo anoLher 8n) lf Lhe paLlenL requlres a healLh assessmenL
analysls Leachlng or nurslng [udgmenL abouL hls or her care Also make sure Lo asslgn procedures and
responslblllLles only Lo a professlonal who's legally permlLLed Lo perform Lhe speclflc Lask

now a ma|pract|ce c|a|m proceeds
8ecause malpracLlce clalms come under sLaLe [urlsdlcLlon Lhe manner ln whlch Lhey're processed may
vary from sLaLe Lo sLaLe Also many sLaLes llmlL Lhe amounL of damages plalnLlffs can recover ln an
efforL Lo curb frlvolous lawsulLs and keep healLhcare provlders' lnsurance premlums aL a reasonable
raLe
ln some sLaLes preLrlal arblLraLlon or a revlew panel may Lake place Cenerally Lhough when Lhe sulL ls
flled lL names defendanLspersons Lhe plalnLlff belleves had a duLy Lo Lhe paLlenL and caused paLlenL
ln[ury by breachlng LhaL duLy
What to do |f you're named |n a su|t
lf you've been named ln a malpracLlce lawsulL noLlfy your malpracLlce lnsurance carrler lmmedlaLely lf
you're sLlll employed aL Lhe faclllLy where Lhe lncldenL occurred noLlfy LhaL faclllLy lf you don'L have
your own malpracLlce lnsurance Lhe faclllLy's legal counsel probably wlll represenL you
lf you kepL onLhe[ob noLes or [ournals revlew Lhem as a memory ald 8uL be aware LhaL you may be
requlred Lo Lurn over Lhese noLes durlng Lhe legal processand LhaL Lhey can be used agalnsL you
?our lnsurance carrler may ask you Lo prepare wrlLLen documenLaLlon lncludlng Lhe Llme and locaLlon
of Lhe lncldenL and Lhe names of any wlLnesses 8e sure Lo convey Lhls lnformaLlon Lo your carrler wlLhln
Lhe Llme frame speclfled by your pollcy mosL carrlers deny coverage lf you don'L meeL Lhelr deadllne
lf you don'L have personal malpracLlce lnsurance hlre an aLLorney Some faclllLles may provlde you wlLh
an aLLorney buL oLhers may wlLhdraw Lhelr supporL of a nurse lf a susplclon of gullL exlsLs or lf Lhey
declde Lhey need Lo cuL Lhelr flnanclal losses
llnally don'L dlscuss Lhe case wlLh anyone excepL your aLLorney who may Lell you noL Lo dlscuss lL even
wlLh your employer or represenLaLlves of Lhe faclllLy lnvolved

G|v|ng a depos|t|on
lf you're named as a defendanL ln a malpracLlce sulL expecL Lo glve a deposlLlonsworn preLrlal
LesLlmony ln response Lo wrlLLen or oral quesLlons and crossexamlnaLlon recorded by a cerLlfled courL
reporLer ueposlLlons also are Laken from Lhe plalnLlff oLher defendanLs and experLs for boLh Lhe
plalnLlff and defendanL
uefendanLs' deposlLlons are meanL Lo clarlfy and ampllfy whaL Lhe paLlenL record shows and Lo
deLermlne whaL Lhe defendanL lnLends Lo clalm LxperLs' deposlLlons are Laken Lo explore Lhe scope of
wrlLLen experL oplnlons uurlng a deposlLlon experLs usually are asked lf Lhey'll be offerlng oLher
oplnlons noL conLalned ln Lhe wrlLLen oplnlons already advanced
8efore your deposlLlon (or your Lrlal lf lL comes Lo LhaL) your aLLorney wlll advlse you on how Lo
conducL yourself and wlll revlew wlLh you Lhe paLlenL's record and Lhe quesLlons you're llkely Lo be
asked 1he aLLorney also wlll Lell you whlch documenLs and dlscusslons you're noL obllgaLed Lo dlscuss
such as rlsk managemenL documenLs (for example lncldenL reporLs) and your dlscusslons wlLh
aLLorneys
uurlng a deposlLlon Lhe deposlng aLLorney (Lhe plalnLlff's represenLaLlve) your aLLorney and Lhe courL
reporLer are presenL CLher persons also may be LhereLhe paLlenL paLlenL's famlly and lawyers
represenLlng oLher defendanLs ln Lhe case
1yplcally Lhe deposlLlon beglns wlLh Lhe deposlng lawyer lnqulrlng abouL your background educaLlon
and experlence and Lhen asklng quesLlons abouL your care of Lhe paLlenL uependlng on how Lhe
quesLlonlng evolves your aLLorney or oLher defendanLs' aLLorneys may ask clarlfylng quesLlons
8ememberdeposlLlons can be used ln a Lrlal and deposlLlon LesLlmony LhaL doesn'L maLch Lrlal
LesLlmony wlll become a polnL of conLenLlon durlng Lhe Lrlal

@ak|ng a proact|ve approach
1o avold malpracLlce clalms Lake Lhe Llme Lo undersLand Lhe legal prlnclples of malpracLlce and
lncorporaLe Lhese lnLo your nurslng pracLlce 8e sure you're famlllar and compllanL wlLh your sLaLe's
nurse pracLlce acL your faclllLy's pollcles and pracLlces and appllcable sLandards of care relaLed Lo your
pracLlce area
Pere are oLher guldellnes LhaL can help reduce your llablllLy rlsk
or help cushlon Lhe flnanclal blow lf you're sued
- erform only Lhose skllls LhaL are wlLhln your pracLlce scope
- SLay currenL ln your fleld or speclalLy area by aLLendlng lnservlce programs and oLher conLlnulng
educaLlon opporLunlLles 8e acLlve ln professlonal organlzaLlons
- know your sLrengLhs and weaknesses uon'L accepL asslgnmenLs lf you're noL sure you're compeLenL
Lo perform Lhem
- ALLend equlpmenL lnservlce programs and make sure you know how Lo deLecL equlpmenL fallures
- never make a sLaLemenL LhaL a paLlenL or famlly member may consLrue as an admlsslon of gullL or
faulL
- uocumenL all paLlenL care acLlvlLles and communlcaLlons
- know how Lo lnvoke Lhe chaln of command ln your faclllLy and don'L heslLaLe Lo do so when needed
- MalnLaln open honesL respecLful communlcaLlon wlLh paLlenLs and Lhelr famllles 1hey're less llkely
Lo sue lf Lhey belleve Lhe nurse has been carlng and professlonal
- Carry your own malpracLlce lnsurance 1haL way lf you're named ln a sulL you'll have an aLLorney
dedlcaLed solely Lo your lnLeresLs WlLhouL lnsurance you musL rely on Lhe faclllLy's aLLorney whose
flrsL prlorlLy ls Lo defend Lhe faclllLy

,ore autonomy greater |ega| r|sk
As nurses we've become lncreaslngly lnLegral Lo healLhcare dellvery and more auLonomous ln our
pracLlce Along wlLh our lncreased role comes greaLer responslblllLy and accounLablllLynoL [usL for our
own acLlons buL for Lhose of personnel Lo whom we delegaLe Lasks We're belng held Lo hlgher
sLandards Lhan ever
SLaff reducLlons and llmlLed resources place even greaLer demands on nurses CfLen we musL acL
qulckly ln hlghpressure slLuaLlons WhaL's more Lhe paLlenLs' rlghLs movemenL has emboldened more
paLlenLs Lo sue healLhcare provlders
All of Lhese facLors make nurses more vulnerable Lo malpracLlce clalms 1o help shleld yourself always
pracLlce wlLhln Lhe boundarles of your professlonal llcensure AlLhough we can'L guaranLee you'll never
be named ln a malpracLlce sulL we're confldenL LhaL Lhe advlce ln Lhls arLlcle wlll help you recognlze
and avoldmalpracLlce plLfalls and perlls

SelecLed references
8rooke S So you've been named ln a lawsulL whaL happens nexL? nurslng 200636(7)4448
CaLalano !1 nurslng now! 1oday's lssues 4Lh ed hlladelphla lA uavls 2006
Croke L nurses negllgence and malpracLlce an analysls based on more Lhan 230 cases agalnsL nurses
Am ! nurs 2003103(9)3463
CurLls L nlcholl P uelegaLlon a key funcLlon of nurslng nurs Manage 200411(4)2631
Clabman M 1he Lop 10 malpracLlce clalms Posp PealLh neLw 200478(9)6063
naLlonal Councll of SLaLe 8oards of nurslng uelegaLlon concepLs and declslonmaklng process naLlonal
Councll poslLlon paper 1993 Avallable aL wwwsLaLe/laus/nurslng/pdf_fllesdelegaLlon1ul
Accessed SepLember 3 2006
lor a compleLe llsL of selecLed references vlslL Amerlcannurse1odaycom

ueanna L 8elslng hu A8n8C ls AssoclaLe rofessor of nurslng aL lndlana unlverslLy School of
nurslng ln 8loomlngLon lnd aLrlcla n Allen MSn A8n8C ls Cllnlcal AsslsLanL rofessor aL lndlana
unlverslLy School of nurslng

Standards of pract|ce (standards of care)
are guldellnes used Lo deLermlne whaL a nurse should or should noL do SLandards may be deflned as
a benchmark of achlevemenL whlch ls based on a deslred level of excellence" SLandards of care (SCC's)
measure Lhe degree of excellence ln nurslng care and descrlbe a compeLenL level of nurslng care
A sLandard ls a model of esLabllshed pracLlce LhaL ls commonly accepLed as correcL 1he care provlded
by nurses ls gulded by sLandards of care SLandards of care were developed and lmplemenLed Lo deflne
Lhe quallLy of care provlded 1hey are Lhe basls for nurslng care and draw on Lhe laLesL sclenLlflc daLa
from nurslng llLeraLure Cllnlcal admlnlsLraLlve and academlc experLs have conLrlbuLed Lo Lhe
developmenL of sLandards of nurslng pracLlce

All sLandards of pracLlce provlde a gulde Lo Lhe knowledge skllls [udgmenL and aLLlLudes LhaL are
needed Lo pracLlce safely 1he sLandards are based on Lhe premlse LhaL Lhe reglsLered nurse ls
responslble for and accounLable Lo Lhe lndlvldual paLlenL for Lhe quallLy of nurslng care he or she
recelves SCC's provlde a means of deLermlnlng Lhe quallLy of care whlch an lndlvldual recelves
regardless of wheLher lnLervenLlon ls provlded solely by a reglsLered nurse or by a reglsLered nurse ln
con[uncLlon wlLh oLher llcensed or unllcensed personnel

1he sLandards of pracLlce shall
1 8e consldered as Lhe basellne for quallLy nurslng care
2 8e developed ln relaLlon Lo Lhe law governlng nurslng pracLlce
3 Apply Lo Lhe reglsLered nurse pracLlclng ln any seLLlng
4 Covern Lhe pracLlce of Lhe llcensee aL all levels of pracLlce

lederal and sLaLe laws rules and regulaLlon and oLher professlonal agencles/organlzaLlons help deflne
sLandards of pracLlce 1hey are developed by professlonal organlzaLlons usually aL Lhe naLlonal level Lo
esLabllsh norms for Lhe average pracLlLloner 1he AnA and !olnL Commlsslon on AccredlLaLlon of
PealLhcare CrganlzaLlons (!CAPC) have esLabllshed naLlonally recognlzed sLandards of care 1hese
sLandards can hold nurses accounLable regardless of Lhelr area or sLaLe of pracLlce SCC's can be found
aL a naLlonal sLaLe and local level 1he Lrend ls Loward naLlonal SCC's All levels of experLlse from new
graduaLe Lo experlence nurse should be able Lo meeL Lhese expecLaLlons of pracLlce

A sLandard of care holds a person of excepLlonal sklll or knowledge Lo a duLy of acLlng as would a
reasonable and prudenL person possesslng Lhe same or slmllar skllls or knowledge under Lhe same or
slmllar clrcumsLances SLandards of care may serve as guldellnes when evaluaLlng nurslng care for
posslble negllgence 1hey deflne acLs LhaL are permlLLed Lo be performed or prohlblLed from belng
performed SCC's glve dlrecLlon Lo Lhe nurse deflnlng whaL should or should noL be done for paLlenLs

Any nurse who does noL meeL accepLed sLandards of care runs a rlsk of belng found negllgenL nurses
who glve compeLenL care based on Lhelr educaLlon wlll seldom be lnvolved ln malpracLlce MosL legal
acLlons agalnsL nurses arlse because a paLlenL clalms Lhe nurse breached a sLandard of care and LhaL Lhe
breach resulLed ln harm Lo Lhe paLlenL MalpracLlce (negllgence on Lhe parL of a healLhcare professlonal)
ls one legal acLlon LhaL a nurse may be charged wlLh for falllng Lo meeL Lhe sLandards of care

nurses have been held accounLable for lnapproprlaLely admlnlsLerlng medlcaLlons falllng Lo proLecL Lhe
paLlenL from harm (le paLlenL who recelves burns from warmlng measures paLlenL who falls ouL of
bed) and falllng Lo monlLor equlpmenL LhaL laLer causes harm Lo Lhe paLlenL noL adherlng Lo Lhe sLaLe
regulaLlons relaLed Lo Lhe delegaLlon of nurslng Lasks Lo nonnurslng unllcensed personnel and
erroneous paLlenL ldenLlflcaLlon can also be Lhe basls of legal llablllLy relaLed Lo nurslng sLandards of
care

Accordlng Lo SCC's a llcensed nurse shall ln a compleLe accuraLe and Llmely manner reporL and
documenL nurslng assessmenLs or observaLlons Lhe care provlded by Lhe nurse for Lhe cllenL and Lhe
cllenL's response Lo LhaL care nurses assume a llablllLy rlsk lf Lhey fall Lo monlLor a paLlenL or Lo
recognlze changes ln a paLlenL's condlLlon lallure Lo recognlze Lhe slgnlflcance of changes or Lo
communlcaLe Lhem clearly and prompLly Lo Lhe aLLendlng pracLlLloner could endanger Lhe paLlenL

nurslng sLandards are lmporLanL because Lhey
1 CuLllne whaL Lhe professlon expecLs of lLs members
2 romoLe gulde and dlrecL professlonal nurslng pracLlce lmporLanL for selfassessmenL
and evaluaLlon of pracLlclng nurses
3 Ald ln developlng a beLLer undersLandlng and response for Lhe varlous and
complemenLary roles LhaL nurses have

rofesslonal sLandards ensure LhaL Lhe hlghesL level of quallLy ln care ls promoLed SLandards provlde a
meLhod Lo assure LhaL cllenLs are recelvlng hlghquallLy care LhaL Lhe nurse knows Lhe essenLlals Lo
provlde nurslng care and measures are ln place Lo deLermlne wheLher Lhe care meeLs Lhese sLandards
SCC's reflecL boLh Lhe carlng and professlonal expecLaLlons of nurslng MeeLlng Lhe sLandard of care
lnvolves belng Lechnlcally compeLenL and keeplng up Lo daLe wlLh nurslng SCC's

8y vlrLue of Lhese sLandards socleLy holds nurses and Lhose under Lhelr supervlslon accounLable for
Lhelr acLlons 1he law generally vlews a sLandard as LhaL pracLlce whlch has general recognlLlon and
conformlLy among professlonals A professlonal nurse supervlses Leaches and dlrecLs Lhose lnvolved ln
nurslng care Culdellnes are essenLlal Lo monlLor how Lhe nurse performs professlonally LxcellenL
nurslng pracLlce ls a reflecLlon of eLhlcal sLandards

1he sphere of a nurse's accounLablllLy ls Lo Lhe cllenL Lhe employlng agency and Lhe professlon
SLandards are agreedupon levels of excellence and descrlbe Lhe responslblllLles for whlch nurses are
accounLable 1he regulaLory pracLlce framework has Lhe prlmary lnLenL of proLecLlng Lhe publlc
CompeLenL nurslng care ls an lmporLanL parL of Lhe healLhcare dellvery sysLem rovlslon of hlghquallLy
care conslsLenL wlLh esLabllshed sLandards ls crlLlcal

1he nurse ls responslble and accounLable for Lhe quallLy of nurslng care glven Lo cllenLs 1he slngle mosL
lmporLanL proLecLlve sLraLegy for Lhe nurse ls Lo be a knowledgeable and safe pracLlLloner of nurslng
and Lo meeL Lhe sLandards of care wlLh all paLlenLs nurses are empowered by Lhe SCC and Lhe LrusL of
Lhe physlclan and Lhe paLlenL Lo ensure quallLy care

1oday's pracLlclng nurse musL be aware of nurslng sLandards legal lssues ln nurslng legal llmlLs of
nurslng and legal llablllLles CLherwlse he or she could be Lhe flrsL person Lo be penallzed from a legal
sLandpolnL Legal responslblllLles ln nurslng pracLlce are growlng ln lmporLance day by day Legal
accounLablllLy ls an essenLlal concepL of professlonal nurslng pracLlce LhaL can pose a LhreaL Lo a nurse's
career lf he or she ls unlnformed of Lhe law Legal lssues confronLlng pracLlclng nurses Loday are leglon
1he nurse need noL vlew Lhe law noL wlLh apprehenslon buL as a helpful ad[uncL Lo Lhe pracLlce of
nurslng

A8Cu1 1PL Au1PC8 ulanne McMahon CerLlfled Legal nurse ConsulLanL
1he auLhor has over 20 years of nurslng experlence ln Lhe cllnlcal and academlc seLLlng She ls a cerLlfled
legal nurse consulLanL She has a bachelors degree ln nurslng from Lhe unlverslLy of Colorado

CopyrlghL McMahon AssoclaLes

More lnformaLlon abouL McMahon AssoclaLes


Whlle every efforL has been made Lo ensure Lhe accuracy of Lhls publlcaLlon lL ls noL lnLended Lo
provlde legal advlce as lndlvldual slLuaLlons wlll dlffer and should be dlscussed wlLh an experL and/or
lawyer lor speclflc Lechnlcal or legal advlce on Lhe lnformaLlon provlded and relaLed Loplcs please
conLacL Lhe auLhor

INCIDLN@ kLCk@S
Porrlble headllnes ln Lhe mass medla abouL medlcal errors are rampanL Lhese days Lveryone has read
or heard abouL Lhe wrong surgery belng performed on a chlld or Lhe wrong slde of a braln belng
operaLed on by a neurosurgeon WhaL abouL Lhe paLlenL who dled from an overdose of chemoLherapy?
1hese sLorles capLlvaLe people and send chllls down Lhelr splnes because LhaL paLlenL could have been
Lhem or a famlly member (1)

aLlenLs Loday are savvy educaLed consumers who are concerned abouL Lhe poLenLlal for acqulrlng an
lnfecLlon Lhe level of care Lhey recelve and Lhe quallflcaLlons of Lhelr healLh care provlders 1hey
belleve LhaL mosL medlcal errors are Lhe resulL of Lhe carelessness or negllgence of Lhelr healLh care
provlders whom Lhey belleve Lo be overworked worrled or sLressed (2) MosL Amerlcans however do
noL undersLand fully Lhe breadLh of healLh care lssues PealLh care Loday ls a complex sysLem comprlsed
of numerous lnLrlcaLe parLs LhaL lnLeracL wlLh mulLlple oLher parLs ln unexpecLed ways varlous levels of
speclallzaLlon and lnLerdependencles exlsL ln lnsLlLuLlons 1hls places healLh care faclllLles aL hlgh rlsk for
accldenLs (13)

1wo large sLudles of adverse evenLs were conducLedone ln Colorado and uLah and Lhe oLher ln new
?ork 1hey found LhaL 29 of adverse evenLs occurred durlng Colorado and uLah hosplLallzaLlons and
37 occurred durlng new ?ork hosplLallzaLlons ueaLh occurred 66 of Lhe Llme ln Lhe Colorado and
uLah evenLs and 136 of Lhe Llme ln Lhe new ?ork evenLs ln boLh sLudles more Lhan 30 of adverse
evenLs resulLed from medlcal errors LhaL could have been prevenLed 1hese resulLs exLrapolaLed Lo Lhe
unlLed SLaLes lmply LhaL aL leasL 44000 Amerlcans dle each year as a resulL of medlcal errors buL Lhls
number may be as hlgh as 98000 More people dle ln a glven year as a resulL of medlcal errors Lhan
from moLor vehlcle accldenLs (43438) breasL cancer (42297) or AluS (16316) (1(p22))
1he esLlmaLed LoLal naLlonal cosL of prevenLable medlcal errors resulLlng ln ln[ury whlch lncludes losL
lncome and uS household producLlon dlsablllLy and assoclaLed healLh care cosLs ls $17 bllllon Lo $29
bllllon annually PealLh care cosLs represenL more Lhan half of Lhls number (le $83 bllllon Lo $144
bllllon) (2) ln addlLlon Lo Lhe moneLary perspecLlve medlcal errors also decrease Lhe LrusL LhaL people
have ln Lhe healLh care sysLem and dlmlnlsh saLlsfacLlon noLed by boLh paLlenLs and healLh care
professlonals hyslcal and psychologlcal dlscomforL accompany longer hosplLal sLays or dlsablllLy when
errors occur lnsLlLuLlons lncur poor publlclLy damaged repuLaLlons and flnanclal llablllLy from medlcal
errors PealLh care professlonals pay wlLh loss of morale and lncreased frusLraLlon aL Lhelr lnablllLy Lo
provlde Lhe besL care posslble ln addlLlon employers and socleLy as a whole pay ln Lerms of losL worker
producLlvlLy reduced school aLLendance by chlldren and poorer healLh of Lhe populaLlon (14)

AccldenLs lnevlLably occurpeople ln all llnes of work make errors Lrrors can be prevenLed however by
deslgnlng sysLems LhaL make lL dlfflculL for people Lo make mlsLakes and easy for people Lo do Lhe rlghL
Lhlng A poslLlve approach Lo rlsk conLalnmenL and conLrol lncludlng learnlng from pasL errors reduces
rlsk When near mlsses occur lnsLead of belng Lhankful noLhlng negaLlve happened nurses should
quesLlon whaL could be learned from Lhe evenL Lo prevenL fuLure occurrences 1hls proacLlve sLance ls
supporLed by Lhe noLlon LhaL Lo prevenL ls cheaper Lhan Lo cure undersLandlng why errors and near
mlsses occur helps nurses lmprove paLlenL safeLy because Lhey learn from prevlous mlsLakes ldenLlfylng
and correcLlng sysLem errors resulLs ln decreased


* personal and faclllLy rlsk llablllLy

* regulaLory sancLlons

* negaLlve publlclLy and

* harm Lo paLlenLs

AlLhough lL may be human naLure Lo make mlsLakes lL also ls human naLure Lo creaLe soluLlons dlscover
alLernaLlve meLhods and meeL fuLure challenges (137)

1he nurslng professlon ls polsed Lo play a key role ln reduclng healLh care errors Cllnlcal and
organlzaLlonal experLlse allows nurses Lo ldenLlfy sysLemsrelaLed errors and help correcL Lhose errors
Slmpllfylng and sLandardlzlng processes developlng backup sysLems analyzlng organlzaLlonal deslgn
and performlng as a Leam all are measures LhaL can be Laken Lo lmprove sysLem rellablllLy and
Lherefore ulLlmaLely prevenL errors and adverse evenLs (3)

INCIDLN@ kLCk@ NC,LNCLA@DkL

1he Lerm lncldenL reporL ls common ln Lhe healLh care envlronmenL 8aLher Lhan a plece of paper Lhls ls
a process ln whlch occurrences LhaL are lnconslsLenL wlLh rouLlne faclllLy operaLlon or paLlenL care are
documenLed lncldenL reporLs are generaLed for four Lypes of medlcal errors near mlsses adverse
evenLs lnLenLlonal unsafe acLs and senLlnel evenLs 1hese evenLs may affecL any person on Lhe
premlses lncludlng paLlenLs employees physlclans vlslLors sLudenLs or volunLeers lncldenL reporLlng
serves Lo

* descrlbe occurrences LhaL are unexpecLed unusual or ouL of Lhe ordlnary rouLlne of a healLh care
faclllLys operaLlons wheLher or noL Lhey cause ln[ury

* provlde Lhe basls for a Llmely and comprehenslve lnvesLlgaLlon of an lncldenL lf necessary

* provlde lnformaLlon wlLh whlch correcLlve or remedlal acLlon may be planned

* provlde raw daLa Lo ldenLlfy rlsk Lrends for recurrlng lssues and paLlenL safeLy rlsks and Lo lnsLlLuLe
procedural changes or lnservlce Lralnlng and

* provlde Lhe lnformaLlon necessary Lo defend sLaff members or healLh care faclllLles (8)

MosL healLh care faclllLles lack a common vocabulary and approach Lo undersLandlng and descrlblng
Lhelr lncldenLs Lrrors ln Lhe undersLandlng of whaL an lncldenL ls may cause undeLecLed changes ln
Lhe quallLy of care rendered and ouLcome evaluaLlons A llsL of words assoclaLed wlLh lncldenL reporLlng
are deflned ln 1able 1 ln addlLlon numerous lnconslsLencles exlsL ln how daLa are collecLed recorded
and analyzed and ln Lhe way errors are lnLerpreLed lor example ls admlnlsLerlng a medlcaLlon laLe
consldered an lncldenL? lf so how laLe ls laLeone hour? lour hours? Cne sLudy demonsLraLed LhaL few
error reporLs were submlLLed when medlcaLlons were admlnlsLered 40 or 30 mlnuLes laLe (7) ln facL lL
was found LhaL medlcaLlons were admlnlsLered laLer Lhan ordered on numerous occaslons as a resulL of
Lhe Llmlng of paLlenLs meals or dlagnosLlc and laboraLory LesLs 1he nurse may noL have consldered Lhls
delay an error CLher reasons for delayed medlcaLlon admlnlsLraLlon could be caused by lnadequaLe
sLafflng or laLe pharmacy dellvery roblems such as Lhese should be ldenLlfled so subsequenL errors can
be prevenLed by maklng approprlaLe sysLem changes 1he lncldenL reporL LhaL ls generaLed ls
lnsLrumenLal ln Laklng correcLlve acLlon (67910)

All healLh care provlders need Lo undersLand Lhe purpose of generaLlng lncldenL reporLs and approprlaLe
reporLlng behavlors ln addlLlon Lo uslng Lhe correcL Lermlnology ersonnel need an accuraLe
undersLandlng of whaL ls a reporLable lncldenL ConLlnued lack of undersLandlng wlll lmpede aLLempLs Lo
valldaLe and lmprove quallLy ouLcomes for paLlenLs (11)

C8ILC@IVLS Ck INCIDLN@ kLCk@ING

1he purpose of lncldenL reporLs ls Lo help healLh care faclllLles ldenLlfy poLenLlal and acLual rlsks and
Lhus ellmlnaLe hazards lncldenL reporLs also alerL rlsk managers Lo poLenLlal lawsulLs LhaL could be
assuaged by early lnLervenLlon lncldenL reporLs have been used for many years as parL of daLa Lracklng
sysLems ln quallLy assurance and rlsk managemenL programs because Lhey help deLecL unusual evenLs
or emerglng problems Accordlng Lo Lhe aLlenL SafeLy Manual publlshed by Lhe Amerlcan College of
Surgeons (ACS) Lhe ob[ecLlve of an lncldenL reporLlng sysLem ls Lo ldenLlfy 100 of adverse paLlenL
occurrences and poLenLlally compensable evenLs (11) 1he Lerm adverse paLlenL occurrence ls deflned as
an unLoward evenL LhaL ls noL a naLural consequence of Lhe paLlenLs dlsease or LreaLmenL under
opLlmal clrcumsLances AnoLher ob[ecLlve of lncldenL reporLlng sysLems ls Lo provlde currenL
lnformaLlon Accordlng Lo Lhe manual lncldenLs should be reporLed and lnvesLlgaLed lmmedlaLely
regardless of wheLher Lhe evenL resulLed ln an ln[ury 1hls daLa Lhen can be used ln a quallLy
managemenL sysLem Lo Lrack Lrends provlde feedback and educaLe all of whlch allow for sysLem
lmprovemenLs ln addlLlon Lhe daLa proLecLs an lnsLlLuLlon by mlnlmlzlng fuLure rlsk and reduclng Lhe
lnsLlLuLlons legal vulnerablllLy ln essence lL serves Lo proLecL nurses paLlenLs and healLh care faclllLles
(1012)
CrganlzaLlons should be encouraged Lo ldenLlfy errors evaluaLe causes and Lake approprlaLe acLlons Lo
lmprove fuLure performance 1hls can be accompllshed vla lnLernal or exLernal reporLlng sysLems whlch
may be volunLary or mandaLory 1he goal for reporLlng sysLems ls noL slmply Lo collecL daLa buL raLher Lo
analyze lnformaLlon and ldenLlfy meLhods so LhaL fuLure errors can be prevenLed 8eporLlng wlLhouL
analysls and followup acLlon ls useless and may even be counLerproducLlve ln LhaL lL weakens supporL
for consLrucLlve responses ln Lhe fuLure (1)

1o lmprove Lhe quallLy of care and cllnlcal safeLy all poLenLlally adverse or nearmlss lncldenLs and
acLual adverse evenLs should be reporLed Lracked ldenLlfled as Lrends and evaluaLed sysLemaLlcally
roper conLrols and reporLlng beLween people needs Lo occur so LhaL lessons are learned educaLlon
and Lralnlng programs are revlewed and updaLed and pollcles procedures and guldellnes are revlsed Lo
bulld on sLrengLhs and lmprove areas of weakness WlLh correcL processes ln place clear llnes of
accounLablllLy for Lhe quallLy and safeLy of cllnlcal care resulL (313)
An example of a poslLlve change occurred aL SL !osephs Wayne PosplLal n! 1wo nurses were parL of
Lhe surglcal Leam durlng a laparoscoplc gynecologlcal procedure 1he nurses asked Lhe surgeon lf he
wanLed Lo send Lhe reLrleved fluld as a speclmen Lo Lhe laboraLory 8oLh nurses undersLood LhaL Lhe
surgeon had responded no 1he surgeon however dlcLaLed ln hls posLoperaLlve summary LhaL Lhe
fluld had been senL Lo Lhe laboraLory upon quesLlonlng hlm afLer lL was dlscovered LhaL Lhe speclmen
was mlsslng he agreed he was noL sure whaL he acLually sald durlng surgery regardlng Lhe fluld 1he
lncldenL reporL generaLed resulLed ln a change ln pollcy and procedure Surgeons now are lncluded
acLlvely ln Lhe speclmen collecLlon process because Lhey are requlred Lo slgn Lhe laboraLory requlslLlon
sllp LhaL accompanles Lhe speclmen SerendlplLously some surgeons acLually add more lnformaLlon Lo
Lhls requlslLlon sllp whlch furLher beneflLs Lhe paLhologlsL or cyLologlsL ln Lhe laboraLory lncldenL
reporLs provlde daLa necessary for examlnlng processes and lmprovlng ouLcomes Lhrough approprlaLe
cllnlcal and admlnlsLraLlve declslon maklng

lncldenL reporLs commonly are used Lo capLure reLrospecLlve daLa regardlng negaLlve paLlenL ouLcomes
(eg falls medlcaLlon errors) Lo prevenL dupllcaLlon of Lhe error lL ls essenLlal however Lo noLe Lhe
condlLlons and facLors LhaL creaLed a poLenLlally harmful slLuaLlon even lf a negaLlve ouLcome dld noL
resulL 1he ob[ecLlve ls Lo develop an lncldenL reporLlng sysLem whereby daLa are collecLed lnLerpreLed
and communlcaLed across deparLmenLs and used as an opporLunlLy Lo lmprove processes 1he sysLems
funcLlon ls noL Lo ldenLlfy aberranL lndlvlduals buL raLher Lo

* lsolaLe llkely human errors and ldenLlfy anLlclpaLory sysLems LhaL mlghL prevenL errors or mlLlgaLe
Lhelr effecLs

* ldenLlfy faulLy sysLems LhaL mlghL Lhemselves be conLrlbuLlng Lo dlagnosLlc lncldenLs and

* suggesL lmprovemenLs Lo Lhese sysLems (1413)

1he goal Lherefore ls Lo deLermlne wheLher an adverse evenL was prevenLable or unprevenLable and
how prevenLlve measures may be lmplemenLed 1he underlylng cause of an error needs Lo be assessed
Lo accompllsh Lhls goal (4) 8eassessmenL and change ln hosplLal pollcles and procedures are poslLlve
ouLcomes from lncldenL reporLs

kLCk@A8LL INCIDLN@S

Cenerally reporLable lncldenLs lnclude any evenL LhaL ls noL conslsLenL wlLh rouLlne hosplLal operaLlon
or paLlenL care kansas law for example deflnes a reporLable lncldenL as an

acL by a healLh care
provlder LhaL ls aL or
below Lhe appllcable
sLandard of care and has
a reasonable probablllLy
of causlng ln[ury Lo a
paLlenL or may be
grounds for dlsclpllnary
acLlon by Lhe approprlaLe
llcenslng agency (16 (p34))
1hls law requlres all nurses Lo reporL lncldenLs LhaL may have resulLed ln subsLandard care

1he Lerm adverse evenL ls deflned as an unLoward lncldenL LherapeuLlc mlsadvenLure laLrogenlc ln[ury
or oLher wrongful occurrence dlrecLly assoclaLed wlLh paLlenL care 1hese are lncldenLs LhaL resulL ln or
have Lhe poLenLlal Lo cause physlcal emoLlonal or flnanclal llablllLles Lo a paLlenL resulLlng ln
unexpecLed lncreased dlsablllLy burns pressure sores or oLher ln[urles 1hose lncldenLs LhaL acLually
cause harm Lo a paLlenL may be Lhe resulL of

* breach of confldenLlallLy

* equlpmenL fallure
* fallure Lo follow pollcy and procedure

* lnadequaLe pollcy and procedure or

* procedural breakdowns (eg consenL noL fllled ouL correcLly consenL noL slgned lmproper paLlenL
LransporL)

1hese evenLs need Lo be reporLed lor an lncldenL Lo be reporLed Lhe observer should have an
awareness LhaL an lncldenL has [usL occurred and recognlze Lhe lmporLance of reporLlng Lhe lncldenL ln
addlLlon Lhe observer musL feel comforLable reporLlng Lhe lncldenL whlch wlll be less llkely Lo occur lf
Lhere ls blame or punlshmenL assoclaLed wlLh Lhe lncldenL (1617)

S@LS Ck kLCk@ING

A nurses flrsL prlorlLy when an error ls recognlzed ls Lo ensure Lhe paLlenLs safeLy llrsL and foremosL
Lhe paLlenL ls made safe and Lhen Lhe physlclan ls noLlfled of Lhe error lf necessary When an error
occurs Lhe nurse ls obllgaLed Lo lnform Lhe paLlenL and hls or her famlly members as auLhorlzed by
appllcable confldenLlallLy sLaLuLes ALLendlng physlclans or Lhelr deslgnee also wlll speak wlLh Lhe
paLlenL or famlly members abouL ln[urles resulLlng from adverse evenLs uurlng Lhls dlscusslon Lhe
avallable opLlons wlll be descrlbed (218)

WnC SnCDLD CC,LL@L AN INCIDLN@ kLCk@" ln general an lncldenL reporL should be compleLed ln
a Llmely manner by Lhe person who flrsL wlLnessed or dlscovered Lhe evenL or by Lhe person mosL
closely lnvolved ln Lhe occurrence lf a noncllnlcal person dlscovers an evenL a cllnlcal sLaff member
helps hlm or her compleLe a reporL ln llorlda anyone can flll ouL an lncldenL reporL 1he mosL llkely
person Lo compleLe such a reporL however ls Lhe person who dlscovers Lhe error even lf Lhls person
dld noL commlL or conLrlbuLe Lo Lhe error (21112) Cne sLudy found LhaL 48 of Lhe nurslng populaLlon
surveyed belleve Lhe nurse who dlscovered Lhe error should compleLe Lhe form and 46 of Lhe
populaLlon surveyed belleve Lhe nurse who made Lhe error should compleLe Lhe form (19)

@nL IVL WS uocumenLaLlon should conslsL only of facLs sLaLed ln a clear conclse ob[ecLlve and
comprehenslve manner uescrlbe Lhe evenL lncludlng Lhe locaLlon dlagnosls paLlenLs menLal sLaLus
and any medlcaLlons or herbal Lheraples Laken by Lhe paLlenL wlLhln 24 hours of Lhe lncldenL (2) 1he
reporL should be compleLed as soon as posslble afLer dlscovery of Lhe lncldenL Lhereby mlnlmlzlng Lhe
poLenLlal Lo forgeL Lhe flner polnLs AccuraLe deLalled and compleLe lnformaLlon whlch ls aL Lhe hearL
of any effecLlve llablllLycuLLlng plan ls Lhe mosL effecLlve Lool ln Lhe lncldenL reporL Cplnlons
assumpLlons and hearsay should be puL aslde 1he flve WS are a useful gulde ln compleLlng Lhe reporL
1he goal ls Lo Lhoroughly undersLand a problem by asklng a serles of layered quesLlons Lo geL closer Lo
Lhe underlylng rooL causes (20)

* WhaL? uescrlbe whaL happened ln deLall

* When? Clve Lhe daLe and Llme of Lhe lncldenL
* Where? uescrlbe Lhe lncldenLs locaLlon

* Who? 1ell who dld whaL Lo whom and who wlLnessed Lhe lncldenL

* Why? uld equlpmenL fall? uld someone fall Lo perform a cerLaln LesL? (12)

1he formaL should be slmple pracLlcal and requlre mlnlmal Llme and efforL Lo compleLe lL can be ln a
checkllsL formaL wlLh approprlaLe space Lo allow for a narraLlve secLlon (21) 1able 2 llsLs daLa LhaL
should be lncluded ln lncldenL reporLs 1he acLual lncldenL reporL form used aL SL !osephs Wayne
PosplLal n! can be found on Lhe documenL sharlng page of SSM Cnllne aL hLLp//www
ssmonllneorg/uocumenLs/LlsLuocumenLs asp A supplemenLal reporL compleLed by Lhe nurse
manager also may accompany Lhe lncldenL reporL Lo descrlbe ln more deLall Lhe lncldenL people
lnvolved conLrlbuLlng facLors Lhe paLlenLs cllnlcal condlLlon afLer Lhe lncldenL occurred and acLlon
Laken and by whom Lo correcL Lhe problem

CCLLA8CkA@IVL AkCACn A collaboraLlve approach ln preparlng an lncldenL reporL helps achleve Lhe
besL resulLs for all concerned Managers play a fundamenLal role ln helplng nurses compleLe lncldenL
reporLs and ensurlng rlsk managers respond declslvely Lo any reporLs of near mlsses lncldenLs or
complalnLs by sLaff members or paLlenLs lL ls lmporLanL Lo have an admlnlsLraLlve pollcy LhaL sLaLes Lhe
sLeps requlred Lo compleLe an lncldenL reporL from Lhe Llme Lhe lncldenL ls dlscovered Lhrough follow
up and resoluLlon of Lhe evenL 1he pollcy should sLaLe Lhe purpose of Lhe lncldenL reporL descrlbe Lhe
responslblllLy of parLlclpanLs sLaLe procedures Lo be followed and allow for daLa collecLlon and follow
up AdmlnlsLraLlvely Lhe organlzaLlon needs Lo ldenLlfy whlch errors should be reporLed why and Lo
whom lor example lf a vlslLor falls should Lhls be documenLed on Lhe same form used when a paLlenL
falls? (911) Managers also compleLe Lhe loop by ensurlng LhaL Lhe person reporLlng Lhe lncldenL ls glven
feedback on any acLlons Laken (36)
1he compleLed form should be revlewed by Lhe deparLmenL manager before belng senL Lo Lhe
admlnlsLraLlon and rlsk managemenL deparLmenLs lncldenLs should be dlscussed openly aL relevanL
deparLmenL meeLlngs and recommendaLlons made Lo avold slmllar fuLure lncldenLs 1he meeLlngs
should be vlewed as an educaLlonal opporLunlLywhaL could have been done beLLer or dlfferenLly Lo
avold Lhe error? llnger polnLlng and blamlng oLhers should noL be Lhe focus of Lhe dlscusslon 8aLher
ldenLlfylng and correcLlng problems ln Lhe sysLem LhaL could lead Lo fuLure errors ls Lhe aLLalnable goal
1hls sysLemsbased approach concenLraLes on sysLems errors and lmprovemenLs Lhrough shared
accounLablllLy Analysls and correcLlve acLlon Lo prevenL lncldenL recurrence focuses on Lhree quesLlons

* Why dld Lhls lncldenL happen?

* WhaL were Lhe conLrlbuLlng facLors?

* Pow can lL be prevenLed ln Lhe fuLure? (61217)

LNSDkING I,kCVLD DALI@ C CAkL

uependlng on Lhe serlousness of Lhe lncldenL or Lrend medlcal dlrecLors governlng board members
and lawyers may become lnvolved ln Lhe lncldenL reporLlng process CompleLlng an lnvesLlgaLlon does
noL ensure LhaL quallLy of care has been lmproved Cngolng observaLlons of cllnlcal and admlnlsLraLlve
lnLervenLlons musL be conducLed Lhrough rouLlne safeLy and cllnlcal lnspecLlons walk Lhroughs
lnformal dlscusslons wlLh sLaff members and aLLendance aL cllnlcal care conferences on a regular basls
ln addlLlon perlodlc revlew of lncldenL reporLs should be conducLed Lo dlscern paLLerns or Lrends LhaL
hlnder Lhe provlslon of safe envlronmenLs 1he hlghesL level of admlnlsLraLlon should revlew approve
and endorse pollcles and procedures for lncldenL reporLlng 1hese lnsLrucLlons should be communlcaLed
Lo mlddle managers and Lhen dlssemlnaLed Lo sLaff members (621) A flow charL of Lhe process ls
shown ln llgure 1

kISk ,ANAGL,LN@ AND LLGAL LIA8ILI@

1he healLh care lndusLry ls dlfferenLlaLed from oLher lndusLrles by lLs exLraordlnary mulLldlsclpllnary
mulLlorganlzaLlonal lnpuL for paLlenL care hyslclans deLermlne Lhe amounL and conLenL of care
rendered Lo a paLlenL 1he healLh care faclllLy produces Lhe care dlrecLed by Lhe physlclan 1he
consumer purchaser and healLh plan share ln declslonmaklng responslblllLles and chooslng LreaLmenL
plans for relmbursemenL whlch heavlly lnfluences Lhe level of care rendered no oLher lndusLry
experlences Lhls level of complexlLyLhere ls no one slngle responslble enLlLy ln healLh care who can be
held accounLable for an eplsode of care 1hls creaLes a unlque seL of llablllLy lssues and challenges ln
recognlzlng and learnlng from errors no doubL Lhe poLenLlal for llLlgaLlon someLlmes may affecL Lhe
behavlor of physlclans and oLher healLh care provlders

When personnel ln Lhe rlsk managemenL deparLmenL have been noLlfled abouL an lncldenL Lhe rlsk
manager lnlLlaLes an lnvesLlgaLlon of medlcolegal ramlflcaLlons and he or she deLermlnes Lhe Lype of
ln[ury lncurred ln Lhe lncldenL and Lhe severlLy of ouLcome ln[ury caLegorles ln lncreaslng order of
severlLy lnclude

* conLuslon cuL or laceraLlon

* spraln or sLraln

* LooLh ln[ury

* fracLure or dlslocaLlon

* emoLlonal or flnanclal llablllLy

* lnfecLlon

* reduced llfe expecLancy

* braln damage or

* deaLh (4)

1he severlLy of Lhe ouLcome also ls classlfled ln lncreaslng order of severlLy as

* emoLlonal only

* LemporarylnslgnlflcanL (le no delay ln recovery)

* Lemporarymlnor or ma[or (le delay ln recovery)

* permanenLmlnor (le nondlsabllng ln[ury)

* permanenLslgnlflcanL ma[or or grave (le dlsabllng ln[ury) or

* deaLh (4)

8lsk managemenL programs seek Lo ldenLlfy and conLrol rlsks and reduce and prevenL ln[urles and
accldenLs 1helr purpose ls relaLed dlrecLly Lo Lhe welfare of Lhe paLlenL 1hese programs esLabllsh a
process Lo deLermlne and mlnlmlze poLenLlal llablllLles and lnclude conslderaLlons regardlng employees
vlslLors and paLlenLs (9) 8lsk managemenL ls a process for

ldenLlfylng assesslng and evaluaLlng
rlsks whlch have adverse
effecLs on Lhe quallLy safeLy and
effecLlveness of servlce dellvery and
Laklng poslLlve acLlon Lo ellmlnaLe or
reduce Lhem (3 (p670))
1he lncldenL reporL ls a Lool for rlsk managers LhaL helps Lhem ldenLlfy and correcL hazardous slLuaLlons
procedures and equlpmenL so LhaL Lhe quallLy of paLlenL care ls lmproved procedures and pracLlces are
modlfled and Lhe rlsk of loss and llablllLy Lo Lhe lnsLlLuLlon ls reduced (17)

ln Lhe evenL LhaL an lncldenL develops lnLo a lawsulL legal counsel ls reLalned by Lhe healLh care
organlzaLlon Lo assess poLenLlal organlzaLlonal llablllLy and poLenLlal clalms for compensaLlon or LorL
clalms 1orL clalms resulL when a courL deLermlnes LhaL negllgence by a healLh care provlder caused
ln[ury or deaLh and [urlsdlcLlonal requlremenLs also are meL Legal llablllLy lncludes clvll (le professlonal
malpracLlce) admlnlsLraLlve (le llcensure) and crlmlnal llablllLy Lxamples of crlmlnal acLs lnclude
mallclous acLlvlLles acLs of gross mlsconducL and repeaLed error and vlolaLlons (23)
1he lncldenL reporL ls noL placed ln Lhe paLlenLs medlcal or admlnlsLraLlve record nor are references
made Lo lL A progress noLe ls enLered ln Lhe charL however descrlblng whaL occurred Lhe resulLs of
evaluaLlon and LreaLmenL provlded no names or excuses should be glven (2) CuallLy assurance daLa
whlch lncludes rlsk managemenL records are proLecLed from legal dlscovery ln some sLaLes SenslLlve
lnformaLlon Lherefore LhaL ls absenL from Lhe paLlenLs records may be lncluded ln Lhe lncldenL reporL
(4) ln Lodays llLlglous envlronmenL however lnformaLlon complled by peer revlewers rlsk managers or
oLhers could be accessed by a plalnLlffs lawyer Lo bulld a case 1he plalnLlff can seek lnformaLlon from
Lhe orlglnal reporLer Lhe people who recelve lnvesLlgaLe or analyze Lhe reporLs and Lhe daLa bank
where Lhe lnformaLlon ls kepL 1wo meLhods LhaL are used Lo proLecL each of Lhese Lhree LargeLs from
belng lnvolved ln a clvll lawsulL agalnsL Lhem or Lhelr colleagues are

* promlslng confldenLlallLy by operaLlonal pracLlce buL wlLhouL full legal supporL ln case of subpoena
and

* lmplemenLlng pracLlcal meLhods LhaL prevenL Lhe reporLer from belng ldenLlflable (eg anonymous
reporLlng deldenLlflcaLlon of reporLed daLa) or renderlng Lhe daLa useless Lo Lhe plalnLlff (1)

1he general rules of evldence and clvll procedure as applled by a sLaLe [udge under parLlcular
clrcumsLances deLermlne wheLher plalnLlffs can have access Lo quallLy assurance daLa or have such
lnformaLlon admlLLed as evldence aL Lrlal 1he person who ldenLlfled reporLed or shared Lhe error
lnformaLlon lndependenL lnvesLlgaLors organlzaLlons LhaL malnLaln lnformaLlon on errors and Lhose
who work for such organlzaLlons could be subpoenaed (1)

lL ls lmperaLlve LhaL nurses noL use Lhe medlcal record as a forum Lo lay blame for errors on oLher
personnel 1he medlcal record as a legal documenL musL conLaln facLual ob[ecLlve descrlpLlve daLa
Sub[ecLlve accusaLory remarks do noL belong ln Lhls documenL 1hese lssues are more approprlaLely
handled by Lhe manager unlL supervlsor or rlsk manager or wlLh an lncldenL reporL
lnLeresLlngly lL has been proposed LhaL Lhere should be nofaulL compensaLlon for medlcal ln[urles 1hls
would ellmlnaLe Lhe adversarlal lnqulry lnLo faulL and blame LhaL currenLly demarcaLes Lhe llablllLy
sysLem ln Lhe unlLed SLaLes AnoLher proposal ls excluslve enLerprlse llablllLy whlch shlfLs medlcal ln[ury
llablllLy from lndlvldual pracLlLloners Lo responslble organlzaLlons ln elLher case Lhe fear of personal
llablllLy for lndlvldual healLh care workers would be removed resulLlng ln ellmlnaLlng Lhe need Lo hlde
errors 1hese Lwo ldeas LogeLher mlghL creaLe an envlronmenL more conduclve Lo reporLlng and analysls
wlLhouL Lhe need Lo proLecL daLa (1)

A more conduclve legal envlronmenL
ls needed Lo encourage healLh care
professlonals and organlzaLlons Lo
ldenLlfy analyze and prevenL errors
wlLhouL lncreaslng Lhe LhreaL of llLlgaLlon
and wlLhouL compromlslng
paLlenLs legal rlghLs lnformaLlon
regardlng errors LhaL have resulLed ln
serlous harm or deaLh Lo paLlenLs or
are sub[ecL Lo mandaLory reporLlng
however should noL be proLecLed (1 (p112))
kC8LL,S WI@n INCIDLN@ kLCk@S

1he ACS has esLlmaLed Lhe percenLage of adverse evenLs ln a hosplLal seLLlng LhaL acLually were
reporLed Lo rlsk managemenL was beLween 3 and 30 before 1983 (4) Cne sLudy demonsLraLed LhaL
lncldenL reporLs rarely were generaLed even when paLlenLs suffered ln[urles as a resulL of medlcaLlon
admlnlsLraLlon and Lhe paLlenLs charLs documenLed such resulLs lL ls lnLeresLlng Lo noLe however LhaL
lncldenL reporLs were more llkely Lo have been flled for prevenLable adverse drug evenLs Lhan for
nonprevenLable ones revenLable adverse drug evenLs usually are more serlous (11)

AnoLher sLudy demonsLraLed LhaL Lhe ma[orlLy of nurses belleved lL was lmporLanL Lo reporL all
lncldenLs 1hlrLyslx percenL of Lhe respondenLs belleved LhaL some lncldenLs do noL need Lo be
reporLed 14 belleved LhaL lncldenL reporLs were noL rellable or valld 14 dld noL belleve LhaL Laklng
Lhe Llme Lo flll ouL lncldenL reporLs would prevenL lncldenLs and 21 doubLed LhaL warnlng slgns for
lmpendlng lncldenLs exlsLed 1wenLy percenL of nurses belleved LhaL supervlsors use lncldenL reporLs
agalnsL employees and 17 reporLed LhaL Lhelr supervlsor used lncldenL reporLs agalnsL Lhem ln Lhelr
evaluaLlons 1wenLyflve percenL of nurses reporLed Lhey were afrald LhaL supervlsors would have a
negaLlve vlew of Lhelr skllls when Lhey reporLed an lncldenL AddlLlonally Lhey dld noL LrusL Lhelr
colleagues Lo flll ouL lncldenL reporLs for errors LhaL lnvolved Lhem (9)
LkCL@ICNS C DNI@IVL CCNSLDLNCLS lncldenLs go unreporLed or underreporLed because of Lhe
many problems lnherenL ln Lhe sysLem llrsL reporLlng relles on sLaff members Lo follow admlnlsLraLlve
pollcles and procedures LhaL can be vlewed as belng dlsclpllnary devlces raLher Lhan learnlng Lools?
PlsLorlcally nurses erroneously have belleved LhaL lncldenL reporLs are used as a punlLlve devlce and wlll
be lncluded ln Lhelr employee records lndeed some managers probably have used Lhem ln Lhls
lnapproprlaLe fashlon uefenslveness Lherefore ls Lhe mosL common lmmedlaLe response Lo an error
made ln healLh care 1he defenslve response ls furLher provoked by flnger polnLlng gullL and
someLlmes coverup of Lhe lncldenL lear of reacLlve behavlors on Lhe parL of supervlsors resulLs ln
moLlvaLlng employees Lo avold reporLlng lncldenLs AdmlnlsLraLlve punlshmenLs lnclude professlonal
dlsclpllne whlch could lnclude embarrassmenL placlng Lhe lncldenL reporL lnLo an employees
permanenL personnel flle and breaklng confldenLlallLy of Lhe lnformaLlon by lnapproprlaLely sharlng lL
wlLh oLher nurses SLaff members Lherefore underuse lncldenL reporLs because Lhey belleve Lhe
lnformaLlon gleaned from Lhese reporLs ofLen ls used by managers Lo punlsh pracLlLloners (691013)

NC CCNS@kDC@IVL VALDL AnoLher reason lncldenLs go unreporLed ls LhaL sLaff members belleve LhaL
Lhe process has llLLle value and does noL resulL ln consLrucLlve changes unforLunaLely acLlons Lo
lmprove processes ofLen are noL Laken (41113) AlLhough Lhls approach ls lnconslsLenL wlLh conLlnuous
lmprovemenL daLa are

rarely used Lo make lmprovemenLs ln
Lhe sysLems and processes uaLa are
noL Lyplcally shared wlLh
oLher healLh care provlders
Lo develop lnLerdlsclpllnary
plans for
lmprovemenL (13(p3))
lncldenL reporLlng should noL be seen as an exerclse ln fuLlllLy SLaff members who are responslble for
compleLlng Lhe paperwork may see lncldenL reporLlng as exLra paperwork and belleve LhaL managers
and admlnlsLraLors do noL acL on Lhese reporLs (6)
LAk C LLGAL AC@ICN A Lhlrd reason lncldenLs go unreporLed or underreporLed ls LhaL personnel feel
Lhe lncldenL wlll resulL ln legal acLlon agalnsL Lhem ln Lhe fuLure (4) lear of legal dlscovery of
lnformaLlon may prevenL healLh care professlonals from belng moLlvaLed Lo reporL and analyze errors
PealLh care professlonals need Lo ensure LhaL daLa are proLecLed Lo prevenL hldlng of lnformaLlon and
repeaLlng of errors (1) As a maLLer of facL when Lhe !olnL Commlsslon on AccredlLaLlon of PealLhcare
CrganlzaLlons (!CAPC) lnsLlLuLed lLs senLlnel evenL reporLlng sysLem lL pursued a federal sLaLuLe Lo
ensure LhaL Lhe daLa reporLed Lo Lhem from healLh care organlzaLlons are noL consldered dlscoverable
(22) An envlronmenL LhaL ls conduclve Lo ldenLlfylng analyzlng and reporLlng errors wlLhouL Lhe LhreaL
of llLlgaLlon and wlLhouL compromlslng paLlenLs legal rlghLs ls lmperaLlve uslng a sysLems approach
such as LhaL whlch wlll be dlscussed ln Lhe second parL of Lhls arLlcle can promoLe such an envlronmenL
(1)

CLher reasons for llmlLed reporLlng of lncldenLs lnclude

* fallure Lo recognlze LhaL an lncldenL has occurred

* lack of undersLandlng regardlng whlch Lypes of lncldenLs should be reporLed

* Llme consLralnLs LhaL lnhlblL Lhe compleLlon of lncldenL reporLs

* relucLance of sLaff members Lo reporL lncldenLs lnvolvlng physlclans

* lnadequaLe pollcy and procedure guldellnes

* fear of undermlnlng Lhe repuLaLlon of oLhers Lhe unlL or Lhe lnsLlLuLlon (le loss of professlonal
lmage)

* fear LhaL Lhe reporL wlll noL be kepL confldenLlal on elLher a personal or organlzaLlonal level and

* feellngs of gullL assoclaLed wlLh quesLlonlng compeLence ln ones self or oLhers (4791113)

Such problems resulL ln employees overlooklng or suppresslng lmporLanL lnformaLlon or avoldlng or
delaylng reporLlng (21)

Powever mlnor an lncldenL glves
rlse Lo some degree of lnsecurlLy ln
boLh employees and Lhelr lmmedlaLe
supervlsorsLhe very people upon
whom successful rlsk conLrol
depends (21 (p23))
roblems wlLh lncldenL reporLs ln general lnclude

* capLurlng only a very small proporLlon of all adverse evenLs because of llmlLaLlons ln volunLary
reporLlng

* collecLlng unrellable or lnvalld daLa LhaL are noL amenable Lo lnLerpreLaLlon

* rarely reveallng anLecedenLs (le underlylng causes) of errors whlch ls cruclal for lnsLlLuLlng effecLlve
prevenLlve measures

* lncorrecLly lnferrlng LhaL Lhe ouLcome of an lncldenL was aLLrlbuLed Lo normal rlsks lnherenL ln medlcal
pracLlce raLher Lhan Lo an laLrogenlc evenL
* managlng Lhe lncldenL lndlvldually wlLhouL reporLlng lL

* noL belng useful as a Lool for Lracklng evenL raLes because Lhe denomlnaLor (le Lhe LoLal number of
occurrences) ls unllkely Lo ever be known

* uslng unclear sLandards deflnlLlons and Lools Lo reporL Lhe lncldenL and

* analyzlng and followlng up on a casebycase basls raLher Lhan aggregaLlng Lhe daLa so LhaL general
Lrends can be ldenLlfled (146791113)

lncldenL reporLlng mlghL lncrease lf Lhe reporLlng efforLs are seen as lmporLanL and producLlve A more
parLlclpaLory approach ls needed ln whlch medlcal sLaff members help develop crlLerla for assesslng
adverse evenLs and help lmplemenL changes 1hls would resulL ln a more comprehenslve and
meanlngful quallLy assurance ouLcome Changes LhaL may resulL ln more lncldenL reporL generaLlon
lnclude faclllLaLlng Lhe reporLlng of lncldenLs changlng Lhe lnsLlLuLlons culLure so lndlvlduals are
comforLable reporLlng and provldlng regular feedback Lo Lhe person compleLlng Lhe reporL
demonsLraLlng LhaL Lhe lnformaLlon provlded ls belng used consLrucLlvely (411)

1he goal of consLrucLlve lncldenL reporLlng sysLems ls Lo achleve a beLLer undersLandlng of a faclllLys
problems as Lhey relaLe Lo paLlenL safeLy 1he approach needs Lo be lnLerdlsclpllnary and wlLhouL blame
Lo fosLer process Lhlnklng and problem solvlng so LhaL Lhe sysLems errors can be correcLed (6) When an
error occurs Lhe common lnlLlal reacLlon ls Lo ascrlbe blame Lo someone 1hls slmpllsLlc aLLlLude
however ls erroneous because even apparenLly slngle evenLs or errors are due mosL ofLen Lo Lhe
convergence of mulLlple conLrlbuLlng facLors (1 (p49)) 8lamlng someone does noL alLer Lhese facLors
Lhereby resulLlng ln posslble recurrences of Lhe error 8aLher all condlLlons LhaL conLrlbuLe Lo Lhe error
should be modlfled 1he problem ls noL bad people Lhe problem ls LhaL Lhe sysLem needs Lo be made
safer (1 (p49))

DALI@ I,kCVL,LN@ INI@IA@IVLS CuallLy lmprovemenL lnlLlaLlves should be employed Lo
Lransform organlzaLlonal culLure from one wlLh a blamlng focus Lo one wlLh a quallLy lmprovemenL and
paLlenL focus Managers need Lo undersLand how Lhey should vlew an lncldenL reporL Lo encourage sLaff
members Lo reporL lncldenLs lndeed when reporLlng of medlcal errors no longer ls seen ln a negaLlve
llghL lncldenL reporLlng wlll lncrease and correcLlve acLlon (eg educaLlon) can Lake place lL ls lmporLanL
Lo assure sLaff members LhaL Lhey wlll noL be LargeLed unfalrly because lL ls sLaff members who are aL
Lhe paLlenLs bedslde and observe errors and near mlsses rovldlng a collaboraLlve and supporLlve
envlronmenL makes lL conduclve for sLaff members Lo selfreporL errors more conslsLenLly and
accuraLely (6923)

nurses should be LaughL Lo reporL all mlsLakes no maLLer how Lrlvlal and regardless of wheLher Lhere ls a
known apparenL harm Lo Lhe paLlenL aL LhaL Llme underreporLlng llmlLs Lhe hosplLals ablllLy Lo develop
effecLlve programs Lo prevenL adverse evenLs and undermlnes rlsk managemenL and paLlenL safeLy
programs (11) lf Lhe reporLlng of lncldenLs ls flawed lnconslsLenL or lncompleLe rellable or valld
concluslons cannoL be reached SLaff members should be educaLed abouL Lhe Lypes of errors Lo be
reporLed and Lhe need for accuracy ln Lhe reporLlng
ln sum Lhe culLural mllleu needs Lo be a blamefree open and honesL envlronmenL Lo lmprove
processes and sysLems of care

All managers and sLaff
need Lo acknowledge
LhaL Lhe rlsks wlLhln
healLh care organlzaLlons
wlll be reduced lf
everyone adopLs an
aLLlLude of openness
and honesLy (3 (p670))
Such a culLure requlres organlzaLlonal accounLablllLy for errors raLher Lhan ascrlblng lndlvldual blame lL
also needs a focus on prevenLlng repeaLed errors (618) lorwardLhlnklng admlnlsLraLors who use a
nonpunlLlve approach are essenLlal ln such an envlronmenL AdmlnlsLraLors should supporL sLaff
members raLher Lhan applylng recrlmlnaLlons dlsclpllnary acLlon and blame Lvery near mlss should be
seen as a free lesson and every lncldenL should be seen as an opporLunlLy SLaff members need Lo feel
comforLable reporLlng lncldenLs lf necessary daLa are Lo be collecLed (3)

Carlng and dedlcaLed professlonals make mlsLakes ln [udgmenL and acLlon SysLems LhaL are deslgned Lo
faclllLaLe heallng and proLecL paLlenLs break down lL ls easy Lo blame an lndlvldual however lL Lakes
courage lnslghL and commlLmenL Lo accepL responslblllLy for Lhose errors and move forward Lo flnd
soluLlons LhaL prevenL Lhe error from recurrlng (2) ln Lhls envlronmenL nurses wlll be commlLLed Lo
quallLy and accompllshlng Lasks effecLlvely 1hls ls necessary for accuraLe and compleLe reporLlng Lo Lake
place
Managers musL consLanLly sLrlve Lo
esLabllsh poslLlve ob[ecLlve aLLlLudes
Loward handllng rlsks ln Lhe way Lhey
convey expecLaLlons concenLraLe on
problems raLher Lhan personallLles
and reward prompLness aLLenLlon
and evldence of progress ln prevenLlve
measures Lmphaslze flxlng noL
regreLLlng (21 (p23))
Speclflc mlsdemeanors should be consldered Lhe excepLlon Lo Lhe general rule of nondlsclpllnary acLlon
(3) 1he LradlLlonal cllnlcal boundarles and a culLure of blame musL be demollshed so safeLy can be
deslgned lnLo Lhe healLh care sysLem

CCNCLDSICN

1he purpose of lncldenL reporLs ls Lo capLure reLrospecLlve daLa Lo ldenLlfy poLenLlal and acLual rlsks
Lhereby ellmlnaLlng hazards CrganlzaLlons should be encouraged Lo ldenLlfy errors evaluaLe causes
and Lake approprlaLe acLlon Lo lmprove fuLure performance and paLlenL safeLy All near mlsses and
acLual adverse evenLs should be reporLed Lracked ldenLlfled as Lrends and evaluaLed sysLemaLlcally
AlLhough Lhere are some problems wlLh Lhe lncldenL reporLlng mechanlsm correcLlve measures can be
employed Lo mlnlmlze or ellmlnaLe Lhese lssues lncldenL reporLs should noL be used as a dlsclpllnary
devlce agalnsL an employeeflnger polnLlng and blamlng creaLes a negaLlve culLure of daLa suppresslon

and denlal 8aLher Lhe goal should be consLrucLlve and proacLlve Lo achleve a beLLer undersLandlng of
Lhe faclllLys problems as Lhey relaLe Lo paLlenL safeLy

1odays paLlenLs are lnformed consumers of healLh care who wanL Lo be educaLed abouL Lhe errors
made when Lhey are hosplLallzed

lf behavlor and pracLlces do noL
change Lhen accldenLs and llLlgaLlon
wlll conLlnue Lo be a draln on healLh
care resources (3)
PealLh care provlders Lherefore musL be LaughL how Lo use lncldenL reporLs correcLly
Pome SLudy rogram
lncldenL reporLs1helrpurpose and scope

1he arLlcle lncldenL reporLs1helr purpose and scope ls Lhe basls for Lhls AC8n !ournal lndependenL
sLudy 1he behavloral ob[ecLlves and examlnaLlon for Lhls program were prepared by 8ebecca Polm 8n
MSn CnC8 cllnlcal edlLor wlLh consulLaLlon from Susan 8akewell 8n MS educaLlon program
professlonal CenLer for erloperaLlve LducaLlon