NURSING Incident Report: Writing

PRACTICE &
SKILL What is an Incident Report?
› An incident report (IR; also called accident report and an occurrence report) is a written,
confidential record of the details of an unexpected occurrence (e.g., a patient fall or
administration of the wrong medication) or a sentinel event (i.e., defined by The Joint
Commission [TJC] as an unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof) involving a patient, employee, or other person
(e.g., a visitor) who is present in the healthcare facility. An IR is used for internal risk
management and quality improvement purposes, and is not part of—nor is it mentioned in
—the permanent patient record if a patient is involved. An IR should be completed each
time an event occurs that deviates from the normal operation of the facility (e.g., a visitor
falls) or deviates from routine patient care (e.g., a medication error)
• What: The purpose for writing an IR is to document the details of an unexpected
occurrence or sentinel event. The written information is analyzed to identity changes that
need to be made in the facility or in facility processes to prevent recurrence of the event
and promote overall safety and quality health care
• How: Writing an IR involves providing an objective, detailed description of what
happened; typically the healthcare facility has a standardized form that is completed by
the person who witnesses the incident or is responsible for the area in which the incident
occurred in the case of an unwitnessed incident. The documented information can vary,
but typically an IR includes details regarding
–who witnessed the incident, which is typically the person reporting the incident
although in some cases there is more than one witness
–who was affected by the incident (e.g., patient, family member, nurse)
–what persons were notified (e.g., treating clinician, fire department)
–what actions or interventions were performed in response to the incident
–the condition of the patient, visitor, or employee who was affected by the incident
Authors • Where: An IR should be completed in all healthcare settings according to facility
Tanja Schub, BS protocol
Cinahl Information Systems, Glendale, CA • Who: IRs can be completed by any licensed healthcare professional who participated
Mary Woten, RN, BSN in or witnessed an incident. Writing an IR should never be delegated to unlicensed
Cinahl Information Systems, Glendale, CA
personnel—although unlicensed personnel should report any witnessed incidents and
provide information that can be included in the IR—and are rarely completed in the
Reviewers
Rosalyn McFarland, DNP, RN, APNP, presence of a patient’s family members
FNP-BC
Darlene Strayer, RN, MBA What is the Desired Outcome of Writing an Incident Report?
Cinahl Information Systems, Glendale, CA
› The desired outcome of writing an IR is to
Nursing Executive Practice Council
Glendale Adventist Medical Center, • document the occurrence of an unexpected event that involves physical or psychological
Glendale, CA injury to a patient, visitor or employee or that increases the risk for injury
• identity changes that need to be made in the facility or to facility processes in order to
Editor prevent recurrence of the event and promote overall safety and quality health care
Diane Pravikoff, RN, PhD, FAAN

Why is Writing an Incident Report Important?

Cinahl Information Systems, Glendale, CA

› Writing an IR is important because it can provide

December 25, 2015 • documentation of quality of care

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2015, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 • information that can help clinicians and administrators evaluate and collaborate to reduce the incidence of patient care
errors and other incidents
• a contemporary record by witnesses of the incident that can be useful in resolving liability issues

Facts and Figures

› In an observational study conducted in 10 internal medicine departments in 8 Dutch hospitals over the course of 5–14 weeks,
investigators found that 42% of the 625 unexpected events reported by hospital staff members were related to medication,
and 10% of events involved patient injury (Lubberding et al., 2011)
› An analysis of IRs regarding medical imaging-related incidents in a teaching hospital in Australia determined that 49%
of incidents were associated with a breakdown in communication (Maeder et al., 2012).Researchers who reviewed a
compilation of information from 15 studies identified the following as reasons why clinical errors are unreported (Wolf et al.,
2008):
• Clinicians’ fears about being considered incompetent, potential legal liability, and the lack of anonymity of documented
persons in the IR
• Lack of information about the error/event and how clinical errors are defined
• Disagreement with the organization definition of clinical error and/or which errors should be reported
• The belief that IRs have no benefit
• Disappointment in the response of administration to prior IR filings
• Belief that the IR process requires too much time and/or effort
› In a study of 1,180 nurse clinicians working in the nursing home setting, researchers found that study participants considered
error reporting to be a difficult process; likelihood of reporting a serious error was higher in nurses who had reported a
serious error in the past (Wagner et al., 2011)
› The decision regarding whether or not an incident has occurred—and whether or not to complete an IR—is made based on
nursing judgment, which varies among nurses as a result of differences in area of nursing practice and experience. Many
nurses are hesitant to complete an IR if little or no patient harm resulted from the incident (Waters et al., 2012)
› Medication errors may result in an adverse event. A systematic review demonstrated underreporting of adverse drug events
occurred in 17 countries; the majority of underreporting occurred in Germany, Spain, Holland, England, Ireland, Portugal,
the United Kingdom, and Sweden. Authors conclude lack of training in the concepts and processes of pharmacovigilance for
healthcare professionals is the main cause for underreporting (Varallo et al., 2014)

What You Need to Know Before Writing an Incident Report

› Safety is the first priority when incidents occur. IRs should be completed only after the condition of the involved patient,
visitor, and/or employee is assessed and appropriate nursing and medical interventions are implemented in response to the
incident
• If the incident involves a patient, the treating clinician should be notified immediately and interventions that are ordered
should be performed. If the incident involves a visitor, he/she may require transport to the emergency department for
evaluation and treatment. If the incident involves an employee, transport to employee health or the emergency department
may be indicated, depending on the degree of injury
› IRs are a necessary component of quality improvement efforts. IRs are analyzed in order to learn exactly what happened,
identify the root cause (i.e., underlying factors), and predict if the incident is likely to recur. Analysis of IRs identifies
changes that need to be made in the facility or in facility processes to prevent recurrence of the incident and promote overall
safety and quality of care. Failure to report incidents prevents the organization from developing and implementing policies
and procedures to prevent the incident from recurring
• Incidents are not limited medical errors or to errors in patient care, but include any unexpected occurrence in the healthcare
facility; examples of incidents that do not involve patients include a visitor falling, a visitor contracting an illness while in
the hospital, and a facility employee tripping over a cord, being injured by a piece of malfunctioning equipment, or being
assaulted by a visitor
• An IR must be completed within a specified period of time, typically within 24 hours of the incident, and delivered to a
nurse manager or to the risk management department according to facility protocol. Completing the IR as close to the time
of the incident as possible results in a more accurate IR
› IRs should be completed for all unexpected occurrences regardless of the degree of harm that occurred or who was involved.
Completing an IR is mandatory for incidents involving patient injury and in the case of sentinel events because these signal
the need for immediate investigation and response, and should be completed if the incident placed a patient, visitor, and/or
 employee at increased risk for harm even if no obvious harm occurred. Incidents that do not result in harm are still indicative
of facility processes that compromise safety in the organization
• Errors associated with the administration of medication (i.e., errors related to inaccurate prescribing, administration of the
wrong medication, improper administration of the correct medication, omitted doses, and administering unscheduled doses)
are some of the most common types of potentially serious patient care errors. Other common reasons for completing an IR
include injury to a patient, visitor, or employee and medical device malfunctions
• According to The Joint Commission (TJC), healthcare organizations and leaders in healthcare organizations must develop
a culture of safety in which there is constant striving for safety; safety must be a primary goal of the organization as
demonstrated by the actions of administrative and clinical leaders. Transparency in the organization is necessary with
regard to errors such that when errors occur, information regarding the error is shared openly and there is a clear and
established process regarding possible disciplinary action. The focus, however, of reporting an error is not to discipline
employees but to initiate a thorough evaluation of the error to reduce the chances that it will be repeated. Clinicians who
report patient care errors should be protected from professional retribution and improper disciplinary action; facility
emphasis on disciplinary action will result in clinicians not reporting incidents (TJC, 2009)
–Organizations must strive to have a culture of safety, not a punitive culture, in order for personnel to feel safe reporting
incidents
–Healthcare professionals have an ethical responsibility to report medical errors (Wolf et al., 2008)
–In 2009, TJC released 14 recommendations designed to support transparency in organizations (for details, see http://
www.jointcommission.org/assets/1/18/SEA_43.PDF
• An IR is not part of the patient’s medical record and is not mentioned or referred to in the patient’s medical record
because the medical record is patient-focused and only includes information that is pertinent to patient care. The IR is
intended for use in risk management and should include information that does not pertain to patient care such as the names
of witnesses who were present at the time of the incident. What should be included in the patient’s medical record is an
objective description of what was observed to have happened, patient assessment information, interventions performed,
and patient outcome Depending on the circumstances of the incident and the severity of the outcome, the nurse or the
healthcare facility may be required to report it to TJC, MedWatch (i.e., a medical products reporting system that is part of
the U.S. Food and Drug Administration), and/or the U.S. Pharmacopeia Medication Errors Reporting Program
› The following should be performed before completing an IR:
• Confirmation that the patient, visitor, and/or employee affected by the incident is safe
• It is also important to confirm that the treating clinician or other appropriate persons have been notified and any ordered
interventions have been performed and referrals made
• Confirmation of the identities of all persons involved
• Receipt of a detailed description of the event if witnessed by an unlicensed team member or other person who is not a
licensed healthcare professional
• Review of the facility protocol for completing an IR
› Collect information and materials necessary to complete the IR, including
• the facility approved IR form
• the names of persons involved or witnesses to the incident
• information regarding supplies or equipment that were involved in the event

How to Write an Incident Report

› Use clinical reasoning and judgment to confirm that an incident has occurred that requires completion of an IR
• Complete an IR even if it is likely to result in disciplinary action and whether or not direct harm has occurred
› Meet and document the statements of the principal parties and witnesses to the event, if applicable
• If information must be obtained from patient or visitors, determine if they require special communication considerations
(e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs if they are present
–Use professional certified medical interpreters, either in person or via telephone, when language barriers exist
• If applicable, assess anxiety level and coping ability of the patient, visitor, or employee involved in the incident; assess for
knowledge deficits regarding writing an IR and provide additional information and emotional support as needed
› Complete the IR form, including but not limited to documenting the following information:
• The identification of the patient, visitor, or employee
• Location, time, and date of the incident
• Names of persons other than the patient/visitor/employee who were involved in the incident, including those who witnessed
but did not participate in the event
 • Physical and emotional status of the patient/visitor/employee before and after the incident
• A detailed, objective description of the incident
• Statements made by the patient/visitor/employee at the time of the incident, which should be quoted verbatim in the IR
• Medical and nursing interventions performed and the affected individual’s response
• Whether or not a treating clinician was contacted for an involved patient, the time of the contact, and if the treating
clinician assessed the patient
• Any additional actions performed (e.g., referral of visitor to the emergency department, malfunctioning equipment sent to
the materials management department)
• All patient, visitor, and/or employee outcomes
› Do not include subjective information such as personal assumptions, conclusions, opinions, and suggestions (e.g., regarding
how similar incidents can be prevented in the future)
› Do not document in the patient’s medical record that an IR form was completed
• As appropriate for incidents involving a patient, document in the patient’s medical record an objective description of what
was observed to have happened, patient assessment information, interventions performed, when the treating clinician was
notified, and patient outcomes
› Verify that the IR form is accurate and sign and date the form
› Submit the IR form to the nurse manager or risk management department according to facility protocol

Other Tests, Treatments, or Procedures That May Be Necessary Before or After

Writing an Incident Report
› The patient/visitor/employee will be appropriately evaluated and treated for injuries related to the event
› The risk management department will be contacted as needed for involvement in the investigation and/or completion of the
IR documentation
› The physical condition of the patient/visitor/employee will be assessed monitored as appropriate according to medical status,
facility protocol, and orders of the treating clinician
› The results of laboratory testing or other diagnostic procedures ordered in association with the incident will become available
and an explanation of their results will be given to the affected party
› The involved patient/visitor/employee will be educated regarding what to monitor for and how to report abnormal clinical
signs and symptoms that could be related to the incident

What to Expect After Writing an Incident Report

› The IR will be completed in accordance with facility protocol and forwarded to the nurse manager or the risk management
department of the facility in which the event occurred
› Information in the IR will be analyzed to identify the root cause of the incident and determine changes that need to be made
in the facility or to facility processes to prevent recurrence of the incident and promote overall safety and quality of care

Red Flags
› The treating clinician should be notified immediately when an incident involving a patient occurs, and should personally
assess the patient if harm has occurred. Visitors or employees should be referred immediately to the emergency department if
they have sustained harm. Depending on the degree of harm, employees may be cared for in employee health
› Failure to report incidents prevents the healthcare facility from developing and implementing policies and procedures to
prevent the incident from recurring

What Do I Need to Tell the Patient/Patient’s Family?

› Educate the patient/visitor about what to expect as a result of the incident
› Explain when the results of any laboratory testing or other diagnostic procedures ordered in association with the condition of
the patient/visitor will become available
› Instruct the patient/family how to monitor for and report abnormal clinical signs and symptoms that may be related to the
incident
References
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SEA_43.PDF
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