Writing the Incident Report

In practice

After the bowel resection, the circulating nurse and Avery, the scrub person, sit down to write the report through the facility's reporting system. They describe the event factually: during heavy bleeding, a package of laparotomy pads was opened and added to the count by its printed number without separation; at the first closing count, the count was one short; recount, search and X-ray followed; the package was found to contain four pads instead of five; the patient had no retained item and no delay beyond the X-ray. They do not write who was to blame, and they do not guess at motives. They do note two system factors: the busy moment when the package was opened, and the absence of a quick way to separate pads during heavy bleeding. Two weeks later, the department's safety committee reviews this report along with two similar ones from other rooms. The committee changes the procedure so that any package added during the case is separated and counted aloud before its pads are used, however busy the field is, and the supply department reports the incorrect package to the manufacturer. At the next staff meeting, the change is explained using this case, without names.