The healthcare professional who witnessed an incident, or the first staff member who was notified about it, should file an incident report. But when should the report be completed and how should an incident report be written? In this article we’ll show you best practices.
When should an incident report be completed?
File an incident report whenever an unexpected event occurs. The incident report is required any time:
- A patient makes a complaint;
- A medication error occurs;
- A medical device malfunctions;
- Anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury
Complete the incident report as soon as possible, while the details are still fresh, but no more than 24-48 hours after the incident occurred.
What information should be included in an incident report?
Who, what, where, when, and how: Incident reports should describe factual information about what happened, answering key questions. Incident reporting needs may vary by organization, but this basic information is generally required:
- Patient name, date of birth, and hospital ID number
- Names of any other affected individuals (e.g., staff or visitors)
- Date, time, and location of the incident
- Name and address of the facility where the event occurred
- Type of incident (e.g., medication error, fall, equipment failure)
- Brief, factual description of the incident, written in chronological order
- Witness name(s) and contact information
- Details and total cost of the injury and/or damage, if any
- Action taken at the time
- Name of the physician who was notified
- Name and contact information of the person reporting the incident (if appropriate)
Best practices on how to complete an incident report
Incident reports should focus on the facts, detailing direct observations, actions taken, the assistance provided, and communications initiated:
- Describe exactly what you saw when you arrived on the scene or what you heard that led you to believe an incident had taken place. When possible, include direct quotes from the patient and/or other involved parties (e.g., a colleague or visitor) and clearly identify the source.
- Add other relevant details, such as your immediate response (e.g., calling for help and notifying the patient’s physician). Include any statement(s) a patient makes that may help to clarify his state of mind.
- Avoid making assumptions. Do not draw conclusions about how the event unfolded or speculate about who or what may have caused the incident.
- Do not assign blame. Do not point a finger at a colleague. The incident report should be a detailed description of what happened, not whom you think is responsible.
Using incident management software to simplify incident reporting
Despite the availability of incident reporting systems, many healthcare organizations still rely on manual, paper-based incident reporting, often using hand-written reports. Manual incident reporting is a time-consuming, costly, error-prone process that has many limitations, including low-quality data and limited flexibility.
Collecting incident data is just the first step in the incident management process. To identify and correct safety problems, the right people have to be able to access, sort, organize and analyze that incident data, something that is very challenging—if not impossible—when using paper reports.
To take full advantage of incident reporting, use incident management software that collects incident data electronically, stores that data in a central database, and analyzes it using proven methods.
Find out more about incident reporting and solutions
- Download our eBook "Blueprints for reporting forms" if you want to know more about developing your own reporting forms.
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