Nursing Network

Happy New Year! NHNA welcomes 2025 with planning for two annual events, a new event, and a new program to launch! The Legislative Town Hall Forum is February 6, 2025 @ 5:30 via zoom. If you have not already registered, visit our website nhnurses.org and scroll down to see our events listed. We will review the pros and cons of approximately twenty-five pieces and legislation and discuss NHNA's position on the bills. You will also learn how you can influence policy by reaching out to your NH House and Senate members and sharing the nursing perspective. As the most trusted profession for twenty-three years, your voice matters! This year we are trying a new and separate Nursing Student Legislative Town Forum to accommodate the academic calendar and ensure we are meeting the specific needs of students. Both events are free, and non-members are welcome to attend.

Later in the spring, on April 4, 2025, at Manchester Community College, we will host our annual Graduating Student Nurse Conference. The theme is Advocacy for Yourself and Your Patients. We have a host of talented speakers and the ever-popular New Nurse Panel, where recent graduates share their pearls of wisdom. The purpose of this event is to welcome new nurses to the profession and introduce them to the only statewide nursing association that supports all nurses in NH no matter their specialty or location. Finally, the Commission on Nursing Practice is developing a new program geared to new nurses by offering a 50% scholarship on dues for membership in NHNA. We recognize the value of diversity within the organization and plan to focus on attracting younger nurses to join us! We believe this will be beneficial both to new nurses who will have the opportunity to network and learn new skills, and to NHNA by opening the door for learning new perspectives and recognizing the talents of this cohort.

If you are a champion of NHNA and want to help spread the word about NHNA in your work setting, please reach out to NHNA.ned@gmail.com. The Commission on Nursing Practice is working on a presentation of the evidence-based benefits of being a member of a professional organization and we would appreciate your involvement in expanding our reach. As always, we love to hear from you about other ways we can serve you or if you want to get involved. There is room for all!

Carlene Ferrier, DNP. MPH, RN, NEA-BC

Executive Director, NHNA

So that patients and employees can benefit from an incident report, nurses need to understand their use. They also need to know how to complete and file a report correctly to protect themselves and their organization from the report being used as part of legal action in a lawsuit brought by a patient.

A safety tool

Incident reports provide a record of an unexpected occurrence, such as a fall or administration of a wrong medication dose, that involved a patient, a family member, or an employee. These reports can be used to identify areas of safety improvement and to educate others about how to avoid similar events in the future.

Nurses should think of the incident report as a safety tool, not a method of assigning blame. Organizations should view these reports through the lens of a culture of safety, which The Joint Commission defines as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.” One tenet of a just culture is to take a nonpunitive approach to reporting and learning from adverse events.

When to file

Nurses should check their organization’s policy and procedure related to when to file an incident report. In general, a report should be filed when something unexpected occurs that results in harm. Sometimes nurses may be unsure whether an event warrants reporting. In this case, it’s best to go ahead and complete a report. Even if the event did not result in harm (for example, the patient did not suffer ill effects after receiving a wrong medication), it’s still important to have a record of the event so that the organization can learn from the event and the risk of a similar event can be reduced.

Typically, a licensed professional, such as a nurse or nurse practitioner, who was part of or witnessed the event completes the form. However, nonlicensed clinicians should report events and provide information as needed for the report. If the event wasn’t witnessed (e.g., the patient fell out of bed when alone in the room), generally the first licensed person who becomes aware of the event should file the report.

Reports should be completed as soon as possible after the event (and within 24 hours) and submitted to the designated person/department. Many organizations now allow employees to file reports online, with the risk management department and the appropriate manager receiving notification. Hospitals, clinics, and other healthcare organizations should make reporting as easy as possible to encourage staff participation.

Traditionally, incident reports have focused on situations where harm occurred, but many organizations now also encourage employees to file reports about “near misses” or “close calls”—events that could have resulted in harm but did not because someone became aware of the problem. An example of a near miss is the nurse who misreads a label on a medication mixed by the pharmacy department and almost administers an incorrect dose. These reports can be reviewed by risk managers and clinicians to determine changes that can be made to avoid future harm. In the case of the medication label, for instance, it might mean making the print on the label larger, so it is easier to read. The Joint Commission calls on organizations to recognize employees for reporting both adverse events and close calls, so lessons can be learned and shared.

Incident reports and legal action

In general, incident reports, which should not be part of a patient’s health record, cannot be used in legal action. Support for this comes from the Patient Safety and Quality Improvement Act of 2005, which established a voluntary reporting system designed to encourage data sharing so that healthcare quality could be improved. The act “provides Federal privilege and confidentiality protections for patient safety information, called patient safety work product.” (To be eligible for these protections, hospitals establish a patient safety evaluation system that provides data to a patient safety organization.)

However, if the report is not completed correctly, it may end up in court. For example, in a Michigan case, the hospital was arguing that it didn’t know the cause of the injury, but a report contained an opinion about how an injury occurred (even though opinions should not be included in incident reports). The report was allowed to be included in the case, and the court issued sanctions against the hospital and its counsel for raising defenses “not well-grounded in fact.”

In addition, a few state rulings have noted that incident reports are not always exempt from use in legal action. For instance, an Illinois court ruled that a “quality-related event report” was not privileged and that a patient suing the hospital should have access to it.

Nurses can lessen the likelihood of an incident report being part of a lawsuit by correctly completing it (see sidebar). If the report ends up in court, an accurate document can help provide evidence that the nurse and organization were not at fault for what occurred.

Completing the report

The report should include a detailed description of what happened. Most organizations have a standard form designed to capture key information such as date, time, and location of the event; name of the person who was affected; names of witnesses to the event; names of those who were notified (e.g., the patient’s physician); the condition of the person affected (e.g., any visible breaks in the skin after a fall); and actions taken in response (e.g., radiograph obtained, malfunctioning equipment sent to biomedical engineering).

Objectivity is key. Any relevant statements made by the person affected by the event or witnesses should be recorded verbatim. It’s also important to note who assessed the patient and the results of that assessment.

Although the incident report is not part of the patient’s health record, nurses should still objectively document the event, including what happened, assessment results, interventions, and follow-up (such as physician notification), in the record.

A helpful tool

Incident reports are often seen as something to be avoided. However, if completed properly, they can provide useful information that can help keep patients and staff safe

Do’s and Don’ts for completing an incident report:

Do…

complete the report as soon as possible after the event (but after the safety of the person affected has been ensured and immediate necessary follow-up is completed).
state only the objective facts that you witnessed or know for certain. For example: “The patient was found on the floor next to his bed.” (NOT “The patient fell out of bed.” This is an assumption.)
include a clear, detailed (but concise) description of what happened.
include relevant direct quotes (use quotation marks) from witnesses and those affected by the event. For example, a family member may have said, “He didn’t want to wear his non-skid slippers and slipped on the floor.”
note interventions done in response to protect the person affected by the incident.
provide a timeline for the event and responses.

Don’t…

include subjective information such as assumptions, opinions, or suggestions for how similar events can be avoided in the future.
document in a patient’s health record that an incident report was completed.
use abbreviations that aren’t readily understood. For example, instead of COPD, spell out chronic obstructive pulmonary disease.

Article references

Albert Henry T. Court should respect privilege tied to quality-related event report. AMA. December 29, 2021. https://www.ama-assn.org/delivering-care/patient-support-advocacy/court-should-respect-privilege-tied-quality-related-event

Engel EVM. Discoverability of workplace incident reports. American Bar Association. June 9, 2020. https://www.americanbar.org/groups/litigation/committees/products-liability/practice/2020/discoverability-of-workplace-incident-reports/

HHS. Patient Safety and Quality Improvement Act of 2005 statute and rule. HHS.gov. 2017. https://www.hhs.gov/hipaa/for-professionals/patient-safety/statute-and-rule/index.html

Kelly C, Gross S. Do hospitals have an adequate patient safety system> MedCity News. March 30, 2020. https://medcitynews.com/2020/03/do-hospitals-have-an-adequate-patient-safety-system/

Kelly C, Gross S. Pennsylvania court interprets scope of Patient Safety Act privileges protections. MedCity News. August 7, 2020. https://medcitynews.com/2020/08/pennsylvania-court-interprets-scope-of-patient-safety-act-privilege-protections/

Schub T, Woten M. Incident report: writing. Nursing practice & skill. Cinahl Information Systems. 2015.
The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert. Revised June 18, 2021.

Waranch L. What?! Incident reports can be discoverable? Waranch + Brown. January 25, 2017. https://waranch-brown.com/wait-incident-reports-can-discoverable/

Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.

This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

Total Incurred: Greater than $220,000

(Monetary amounts represent only the payment made on behalf of the insured registered nurse and does not reflect payments made on behalf of the other parties involved in the claim.)

Summary

A 77-year-old male patient underwent a total left hip arthroplasty due to multiple years of arthritic pain. The patient’s medical history included mild-moderate Alzheimer’s disease, gait dysfunction (related to arthritic hip), and occasional incontinence (due to radical prostatectomy for prostate cancer, five years prior).

After a successful total left hip arthroplasty, the patient remained in the hospital a few days due to a sudden increase in the severity of his Alzheimer’s. The family refused all referrals to a rehabilitation facility for post-surgical physical therapy and treatment to stabilize his Alzheimer’s. Instead, the patient’s wife insisted that she could care for him at home with the help of their children and home health services.

On the day of discharge from the hospital, a home health nurse met the patient and family at their home for admission. The nurse noted that the patient was slightly confused, but was easily refocused. The nurse also noted that the patient was a large man (6’ 5”, 260 pounds) and currently chair-bound requiring a one-person assist to stand, but could ambulate using a walker.

The admitting nurse noted the patient had a good support system which consisted of his wife and three daughters who lived locally and were able to assist with his care. The plan of care was for the patient to receive nine-weeks of:

physical therapy, three times-a-week,

wound care treatment to the left hip incision site, three to five times-a-week, and

personal care assistance, three to five times-a-week.

During the first week of home care, the patient made little progress in physical therapy.

At beginning of week two, the wife complained to the insured nurse (defendant) that over the weekend the patient would not doing anything on his own, refused all medications and at times became verbally aggressive.The wife explained that his behavior was polar opposite from his normal character.

The wife stated that due to her size (5’ 0”, 120 pounds) it was difficult for her to get the patient to the bathroom, so she would leave his adult briefs on until her daughters arrived and were able to assist.

After several attempts, the patient reluctantly allowed the nurse to change the dressing to his incision site. The incision site was slightly red, but did not appear infected. The nurse contacted the patient’s primary practitioner about the patient’s behavior and was given an order to increase his Aricept dosage, which the patient began that day.

Two days later, the nurse returned to the patient’s home. The wife stated that the patient’s aggressive attitude had improved, but he still refused to get out of his chair. The wife also informed the nurse that the patient had a bruise-like area on left inner buttocks.

The nurse assessed the area and noted it as a Stage II pressure ulcer. She obtained an order for wet-to-dry dressings and taught the family on wound care and pressure ulcer prevention. She encouraged the family to purchase a ‘donut pillow’ for the patient.

At the next nursing visit, the insured noted the pressure ulcer to be “Stage II 1x 0.5 open area on the left buttock, wound bed pink, no drainage, and surrounding skin intact.” She documented that the “family was taught how to do dressings, advised to do dressing changes 2x per day, educated on how to avoid pressure sores, and to keep pressure off area as much as possible”. She further documented that “patient spends most of his day sitting, is fearful of walking, and is unsteady on his feet”.

Over the next two weeks, the pressure ulcer continued to worsen, despite the nurse contacting the referring practitioner for additional wound care orders.

Three weeks after the pressure ulcer was discovered, a second wound appeared on the patient’s right buttocks. The insured nurse made numerous suggestions to her manager for the patient to be evaluated by a wound-care specialist, but her requests were denied as the manager felt it was unnecessary.

Over the next month, the patient’s medical status and pressure ulcers continued to worsen. Several attempts were made to counsel the family about transferring the patient to a rehabilitation facility, but the family refused. Ultimately, the patient was diagnosed with sepsis and died due to irreversible disease.

Risk Management Comments

After the lawsuit was filed, the insured nurse retired from nursing. She had been a nurse for over 30-years.

The home health agency’s manager testified that she thought the insured was just being lazy and didn’t want to take care of the patient’s pressure ulcers.

The referring practitioner testified that he was unaware of the severity of patient’s pressure ulcers until the ulcers had progressed to a Stage III/IV.

Experts determined that the insured nurse breached the nursing standard of care in the following areas including:

Not staying current on appropriate pressure ulcer treatment.

Failure to monitor the patient care environment to ensure patient safety.

Failure to follow institution’s policies and procedures regarding the chain of command.

Failure to accurately document care, observations and conversations with practitioners, colleagues, patients, family and /or caregivers.

Resolution

Given the deviations from the standard of care and the pejorative testimony from other staff members regarding the defendant’s care, the decision was made to settle the case on behalf of the defendant.

Risk Management Recommendations

Invoke the chain of command when necessary to focus attention on the patient’s status. Nurses are the patient’s advocate, ensuring that the patient receives appropriate care when needed.

Monitor and document the patient’s symptoms, response to treatment and changes in condition in the patient care record.

Timely report all significant findings to the patient’s physician.

Know and comply with your state scope of practice, nurse practice act and facility policies, procedures and protocols. Know the organization’s policies and procedures related to clinical practices and documentation.

Maintain clinical competencies relevant to the patient population and healthcare specialty. Nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers, and ultimately to society.

When faced with a patient situation that has legal implications, proceed in a manner that provides the best care for the patient.

Guide to Sample Risk Management Plan

Risk Management is an integral part of a healthcare professional’s standard business practice. Risk Management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks — a good Risk Management Plan will help you perform these steps quickly and easily!

Visit nso.com/riskplan to access the Risk Management Plan created by NSO and CNA. We encourage you to use this as a guide to develop your own Risk Management Plan to meet the specific needs of your healthcare practice.

Article references

The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2018 CNA. All rights reserved.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Suite 250, Fort Washington, PA 19034-3278. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc. (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc. (CA 0G94493); Aon Direct Insurance Administrators and Berkely Insurance Agency; and in NY, AIS Affinity Insurance Agency. © 2018 Affinity Insurance Services, Inc.

Featuring Speakers:

REGISTER TO ATTEND HERE

SAVE THE DATE

Annual Graduating Student Nurse Conference

When: April 4th, 2025

Where: Manchester Community College

Position Description:

Time Required: 3-5 hours per month

Desired Experience:

A safety tool

When to file

Incident reports and legal action

Completing the report

A helpful tool

Do’s and Don’ts for completing an incident report:

Do…

(Monetary amounts represent only the payment made on behalf of the insured registered nurse and does not reflect payments made on behalf of the other parties involved in the claim.)

Summary

Risk Management Comments

After the lawsuit was filed, the insured nurse retired from nursing. She had been a nurse for over 30-years.

The home health agency’s manager testified that she thought the insured was just being lazy and didn’t want to take care of the patient’s pressure ulcers.

The referring practitioner testified that he was unaware of the severity of patient’s pressure ulcers until the ulcers had progressed to a Stage III/IV.

Experts determined that the insured nurse breached the nursing standard of care in the following areas including:

Resolution

Given the deviations from the standard of care and the pejorative testimony from other staff members regarding the defendant’s care, the decision was made to settle the case on behalf of the defendant.

Risk Management Recommendations

Guide to Sample Risk Management Plan

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