A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)
A.
An approximate amount of urine was recorded after the urine leaked from the client’s catheter bag.
B.
A client received an 0900 daily medication at 1000.
C.
A client who has an infection refused the evening meal.
D.
A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing.
E.
A client fell when ambulating to the bathroom alone.
The nurse should write an incident report for the following events:
B. A client received an 0900 daily medication at 1000.
E. A client fell when ambulating to the bathroom alone.
Explanation:
Event B: Medication Administration Delay An incident report should be completed when there is a deviation from the standard procedure, such as a delay in medication administration. In this scenario, the client’s 0900 medication was given at 1000, which is an hour late. Medication administration delays can potentially affect the client’s health, treatment efficacy, and overall safety. Even though the delay might seem minor, it is crucial to document such occurrences to assess any potential impact on the client’s condition and to identify areas for improvement in the medication administration process. Incident reports help to ensure that all deviations from the standard protocols are recorded and addressed, thus contributing to the overall safety and quality of care.
Event E: Client Fall Falls are significant events in healthcare settings, often resulting in serious injuries or complications. When a client falls while ambulating alone, it constitutes an incident that requires documentation. The incident report should detail the circumstances of the fall, such as the client’s condition prior to the fall, any contributing factors (e.g., lack of assistance or environmental hazards), and any injuries sustained. Reporting such incidents is essential for investigating the cause, implementing preventive measures, and ensuring the safety of other clients. Falls can indicate systemic issues such as inadequate supervision, lack of safety equipment, or insufficient client education, making it crucial to document and analyze these events comprehensively.
Events C and D:
- Event C: A client refusing a meal due to an infection is a typical occurrence in clinical settings and does not generally require an incident report unless there are specific concerns about the client’s nutritional status or medical condition.
- Event D: Administering an antibiotic before a blood culture and sensitivity test might affect test results. However, this situation usually warrants a different type of documentation or correction in the clinical record rather than an incident report unless it led to a specific adverse outcome.
Event A: Recording an approximate amount of urine due to a catheter leak does not constitute an incident requiring a formal report unless it is part of a larger pattern of concerns or if it led to significant complications.