by Joe Bryowsky RN, CCRN – Clinical Manager
Incident reports play an integral part in preventing, detecting and investigating medical errors. They help to maintain a safe environment for patients, visitors and employees. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, visitor or staff member is injured or involved in a situation with the potential for injury, an incident report is required.
Examples include, but are not limited to:
- Needle sticks
- Falls
- Procedure errors
- Misuse of, or faulty equipment
- Other types of injuries or accidents
- Property loss or damage
- Theft
- Fires
Most events or errors happen because of process issues:
- Many “little” failures lead to a “bigger” failure
- Rarely a “person” failure
The incident report should be completed immediately (or as soon as possible) by the employee involved or the employee giving care at the time of the incident.
When filling out an incident report remember to include only the facts. Include the full names of anyone involved and of any witnesses, as well as how, or if they were affected. Describe what you saw or heard that led you to believe an incident had taken place. Be sure to use only nonjudgmental and non- criticizing statements when filling out an incident report.
***Remember to record all clinical observations in the chart, not in the incident report.
Most hospital policies dictate not to make any mention of the incident report in the patient record but this varies widely from hospital to hospital. Always make sure you familiarize yourself with the hospitals policy before having to file an incident report.
There is a lot of controversy as to whether a patient’s attorney can request and receive an incident report and use it in a malpractice lawsuit. The law varies from state to state but most hospitals label the incident report as an integral part of the quality assurance process, which usually suffices to keep the reports from being discoverable.