INCIDENT REPORT:

What exactly is an incident report?

• The definition is simple: An incident report in nursing is a report which
details an event where a person is injured, or property is damaged,
threatening patient, visitor, or staff safety. Although this seems
straightforward, an “event” isn’t always obvious.
• There are three types of incident reports:
a) Sentinel Event: Any unanticipated event in a healthcare setting that result
in death, or serious physical or psychological injury to a patient, staff
member, or visitor. If the event involves a patient, it is not related to the
natural course of the patient’s condition. These are the events that are
clear-cut: A fatal medication error; a nurse is attacked and beaten by a
patient; an infant is abducted from the nursery.
b) Minor Event: An inaccurate name for this type of incident report, this is any
unplanned event that results in an injury or property damage, no matter
how insignificant it seems. Examples: A patient trips on their IV pole; a
nurse cuts their finger while opening a vial; a wheel on the medication cart
is broken.
c) Near-Miss: Unplanned events where no one was injured or property was
damaged, but with a different action, position, or time, they could have
been. Examples: The nurse realizes they are about administering the wrong
medication; a housekeeper mops up a spill and forgets to place a caution
sign; a smeared label on a specimen is difficult to read.

Why are incident reports important?

• They protect YOU. When it happens, a well-Documented incident report
can actually save your nursing license and career.
• They protect your organization. If a patient or their family decides to file a
lawsuit against the organization (which can also include you), it will be
essential for the organization to show that policies were followed, an
 incident report was filed, and appropriate departments or people were
notified.
• They result in better patient care and an improved work environment.
• They create a “reporting culture” that encourages staff to participate.
• They make restitution easier. Without an incident report, it’s impossible for
administration to be fair and accurate in providing compensation for injury,
loss, or damage.

What is included in a perfect incident report?

Workplaces have either designated software or a specific form to complete
an incident report. These make it easy to include the necessary
components of the report.
Your documentation will provide every detail, written in a professional and
objective style.
Here is the “Baker’s Dozen” of elements in a perfect incident report:
ADMINISTRATIVE INFORMATION
1. Your name and title
2. Date and time of the incident
3. Exact location of the incident
INCIDENT INFORMATION
4. Details of the events leading up to the accident
5. Description of the incident, in chronological order
6. Description of all injuries and/or damage
WITNESS INFORMATION
1. Current observations about the incident area
2. Witness full names and contact information
3. Witness statements

ACTIONS AND RECOMMENDATIONS

1. Actions that you took to give aid

2. Actions that you took to prevent further injury/damage
3. Recommendations to prevent another event
FINAL SECTION

1. Documentation finalization and sign-off

What else should you know about writing an
incident report?
The incident report itself is very straightforward. However, it can be
challenging to provide the necessary details in an objective manner; it’s
tempting to make assumptions or place blame, especially away from
ourselves.
Here are some tips from legal professionals.
• An incident report should be filed for ANY unexpected event. Period.
Years can pass between the time of the event and when a lawsuit is
filed. You will never remember all the details, so recording them in
real time—and separate from the medical record—can make all the
difference in the outcome.
• Remember that the patient’s medical record does NOT include
mention of the incident report. The report belongs to risk
management or administration. If it becomes part of the medical
record, the patient’s lawyers can argue that it be turned over to
them.
• Stick to the facts. Do NOT speculate about who or what might have
caused the event. Simply state what happened in clear and concise
terms. For example, write “Patient who usually uses a walker slipped
and fell going to the bathroom. Patient was not using their walker at
the time of the fall.” Do NOT write, “Patient slipped and fell going to
the bathroom. They should have been using their walker.”
• Present the facts in chronological order. Make notes of exact times
and what happened. Start at the time you arrive on the scene or
discover the event. Example: “0920: Entered patient’s room to
administer medication. 0921: Verified patient’s identity. 0922:
Discovered medication was not the same dose as prescribed. Did not
administer. 0924: Notified pharmacy of the discrepancy.”
 • Include photos and videos. If your organization allows, taking photos,
audio, and/or videos can provide valuable supplemental information.
Technology makes it possible to document events in real time, with
greater accuracy, allowing for proper investigation and resolution of
unplanned incidents.
• Avoid judgment. Never include your opinion about how the incident
occurred. Do NOT blame the physician who wrote the wrong order,
the nursing assistant to do raise the bedrail, or the housekeeper who
left their cart in the middle of the hall. These can have serious
implications for those mentioned in the document, as well as
yourself.
• Use quotation marks for anything that the patient or a witness
states. Quotation marks indicate details from another person’s
perspective, in their exact words. Do NOT document “Patient stated
they were wrong to get out of bed without help.” Instead, write,
“Patient stated, ‘I was wrong to get out of bed without help.'” The
difference is enormous, because it goes from subjective to objective
• Include your own actions. Don’t forget to document the actions you
took. Did you provide emergency care? Call the Rapid Response
Team? Notify the family? Clean up the mess? Label defective
equipment and place it out of the way? Show how you responded in
a professional and thorough manner.

Incident reports are part of nursing, too

You probably didn’t learn much about incident reports in nursing school.
They are a normal part of a nursing career and are not likely to go away.
When filed promptly and completely, they are the best way to protect you
from malpractice and other legal action.

When you accurately document an unplanned situation, you should have

nothing to worry about. No matter how trivial the event seems, filing
incident reports is part of every nurse’s job description.