High-risk areas in health care fall into five general categories:

● Medication errors ● Complications from diagnostic or treatment procedures ● Falls ● Patient or family dissatisfaction with care ● Refusal of treatment or refusal to sign consent for treatment

Nursing is involved in all areas, but the medical staff may be primarily responsible in cases involving refusal of treatment or consent to treatment.

Medical records and incidence reports serve to document organizational, nurse, and physician accountability. For every reported occurrence, however, many more are unreported. If records are

78 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS

faulty, inadequate, or omitted, the organization is more likely to be sued and more likely to lose. Incident reports are used to analyze the severity, frequency, and causes of occurrences within the five risk categories. Such analysis serves as a basis for intervention.

Incident Reports Accurate and comprehensive reporting on both the patient’s chart and in the incident report is essential to protect the organization and caregivers from litigation. Incident reporting is often the nurse’s responsibility. Reluctance to report incidents is usually due to fear of the consequences. This fear can be alleviated by:

● Holding staff education programs that emphasize objective reporting ● Omitting inflammatory words and judgmental statements ● Having a clear understanding that the purposes of the incident reporting process are

documentation and follow-up ● Never using the report, under any circumstances, for disciplinary action.

Nursing colleagues and nurse managers should not berate another employee for an incident, and never in front of other staff members, patients, or patients’ family members. Peer review analysis, however, is a valuable tool to evaluate incidents (Hitchings et al., 2008).

A reportable incident should include any unexpected or unplanned occurrence that affects or could potentially affect a patient, family member, or staff. The report is only as effective as the form on which it is reported, so attention should be paid to the adequacy of the form as well as to the data required.

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