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ANY TIME AN incident occurs at your facility, you must fill out an incident report. An incident report (also called an event report or occurrence report) is a formal report written by practitioners, nurses, or other staff members. It serves two purposes:
* to inform facility administrators of incidents that allow the risk management team to consider changes that might prevent similar incidents
* to alert administration and the facility insurance company of potential claims or need for further investigation.
The forms used for incident reports are consistently being revised and updated, and some may be electronic (see What an incident report looks like). Most healthcare facilities provide guidelines for when incident reports must be completed.
In general, an incident is any event that affects patient or employee safety. In most healthcare facilities, injuries, patient complaints, medication errors, equipment failure, adverse reactions to drugs or treatments, or errors in patient care must be reported. Data from incident reports are tracked for quality assurance and to allow the detection of emerging trends or problems. Incident reports bring problems to light in a nonblaming way and can provide a catalyst for changing the practice or procedure that contributed to the error.
An incident report should be initiated only by someone who directly observes the incident or by the first person to arrive at the site of the incident.
When filling out an incident report, include the following information:
* the exact time and date
* the names of persons involved and any witnesses
* factual information about what happened
* other relevant facts, including your actions (such as notifying the healthcare provider) and any corrective actions taken.
After completing the incident report, you must sign and date it. If your incident reports are filed electronically, the form will require you to type in this information.
Follow your facility's policy regarding the policies and procedures for how the incident report is to be followed up; this will determine whether the matter needs further investigation. If the incident directly involved a patient, notify the healthcare provider.
Here are some valuable tips for completing an incident report.
Write objectively. Describe exactly what you saw. If you didn't see the patient fall, document that you found the patient lying on the floor. Then document your actions, such as assessment of the patient for injury, assisting the patient back to bed, and calling the healthcare provider.
Incorporate patient and witness accounts of the event into the report. State their comments as direct quotes. Have the witnesses assist you in preparing the report and co-sign the final report.
Don't assign blame. Refrain from pointing your finger at a coworker or your facility's administration. An incident report isn't an opportunity for you to point out inferior equipment or poor staffing. Just state the facts.
Avoid hearsay and assumptions. If your patient is injured in another department, it's up to the person who witnessed the incident in that department to write the incident report.
Forward the report to the person designated by your facility's policy. Ensure that only one copy of the report exists. If other departments or committees would like to see the report, the original may be forwarded to them in succession.
Because memories fade relatively quickly after an event occurs and critical components may be forgotten, it's vital to document what happened right away. An incident report is factual and complete; it doesn't include excuses for behavior or actions. The incident report is not a part of the patient's medical record. In most courts, the incident report is protected from discovery by the opposing attorneys. If you document the incident report in the patient's medical record, you've lost that protection.
In addition to filling out the incident report, you must document the facts of the event in the patient's medical record. The medical record documentation, completed close to the time of the incident report, should contain only factual, objective, descriptive documentation relative to the patient's condition and response to the incident. Never try to hide or cover up a mistake.
To promote effective reporting and achieve quality care, facilities need to adopt what's referred to as a "just culture." The just culture recognizes that it's rare for any single nurse to be the cause of an incident; instead, multiple system factors often combine to create the circumstances. The just culture eliminates punitive action against the person filing out the incident report and encourages looking beyond the incident to determine other factors. These factors may include orientation and training, staffing ratios, and other issues influencing patient safety.
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Complete Guide to Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
Ditmer D. Risk Management Strategies for Health Care Providers. Eau Clair, WI: PESI Health Care Webinar; 2008.
Guido GW. Legal Issues in Nursing. 4th ed. Stanford, CA: Appleton and Lange; 2005.
Iedema R, Flabouris A, Granti S, Jorm C. Narrativizing errors of care: critical incident reporting in clinical practice. Soc Sci Med. 2006; 62(1):134-144.
Scott RW. Guide for the New Health Care Professional. Sudbury, MA: Jones & Bartlett Publications; 2006.
Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114(3):729-735.
Timby BK. Fundamental Nursing Skills and Concepts. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
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