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
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