Charting Checkup

Dont be intimidated by incident reports

By JoElla Hynes, MSN Clinical Nurse Educator Edward Hospital Naperville, Ill.

ANY TIME AN incident occurs at your facility, you must ll 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. Dening an incident 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 rst person to arrive at the site of the incident. Fill in the blanks When lling 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 led electronically, the form will require you to type in this information.
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Follow your facilitys 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. Tips to get it right Here are some valuable tips for completing an incident report. Write objectively. Describe exactly what you saw. If you didnt see the patient fall, document that you found the patient lying on the oor. 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 nal report. Dont assign blame. Refrain from pointing your nger at a coworker or your facilitys administration. An incident report isnt an opportunity for you to point out inferior equipment or poor stafng. Just state the facts. Avoid hearsay and assumptions. If your patient is injured in another department, its 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 facilitys 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. Act quickly Because memories fade relatively quickly after an event occurs and critical components may be forgotten, its vital to document what happened right away. An incident report is factual and complete; it doesnt include excuses for behavior or actions. The incident report is not a part of the patients medical record. In most courts, the incident report is protected from discovery by the opposing attorneys. If you document the incident report in the patients medical record, youve lost that protection. In addition to lling out the incident report, you must document the facts of the event in the patients medical record. The medical record documentation, completed

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close to the time of the incident report, should contain only factual, objective, descriptive documentation relative to the patients condition and response to the incident. Never try to hide or cover up a mistake.

What an incident report looks like

When you witness or discover a reportable event, you must ll out an incident report. Forms vary, but most include the following information.

Incident report
DATE OF INCIDENT TIME OF INCIDENT

Name of person involved Greta Manning Address

7 Worth Way, Boston, MA (617) 555-1122

3-20-09 4-Main, Rm. 447

TYPE OF INCIDENT (CHECK ONE ONLY) PATIENT

1442

Phone

EXACT LOCATION OF INCIDENT (Bldg, Floor, Room No, Area)

Medical record number (if patient)

VISITOR

EMPLOYEE

VOLUNTEER

OTHER (specify)

, Patient s wife found on floor next to bed. States, I was trying to put Just culture the siderail of the bed down and I fell down. To promote effective reporting FLOOR CONDITIONS OTHER FRAME OF BED LOW NIGHT LIGHT YES Patient and achieve quality CLEAN & SMOOTH SLIPPERY (WET) HIGH NO fall WERE BED RAILS PRESENT? OTHER RESTRAINTS (TYPE AND EXTENT) incidents care, facilities need N/A NO 1 UP 2 UP 3 UP 4 UP to adopt whats reAMBULATION PRIVILEGE UNLIMITED LIMITED WITH ASSISTANCE COMPLETE BEDREST OTHER ferred to as a just WERE NARCOTICS, ANALGESICS, HYPNOTICS, SEDATIVES, DIURETICS, ANTIHYPERTENSIVES, OR culture. The just ANTICONVULSANTS GIVEN DURING LAST 4 HOURS? culture recognizes YES NO DRUG AMOUNT TIME Patient PHYSICIAN NOTIFIED DATE TIME COMPLETE IF APPLICABLE that its rare for Name of Physician incidents J. Reynolds, MD 3-20-09 1445 any single nurse to JOB TITLE SOCIAL SECURITY # Employee DEPARTMENT incidents be the cause of an MARITAL STATUS incident; instead, NOTIFIED DATE TIME LOCATION WHERE TREATMENT WAS RENDERED All multiple system C. Jones, RN 3-20-09 1500 incidents factors often comNAME, ADDRESS, AND TELEPHONE NUMBERS OF WITNESS(ES) OR PERSONS FAMILIAR WITH INCIDENT - WITNESS OR NOT bine to create the Janet Adams (617) 555-0912 1 Main St., Boston, MA circumstances. The just culture SIGNATURE OF PERSON PREPARING REPORT TITLE DATE OF REPORT Connie Smith, LPN LPN 3-20-09 eliminates punitive PHYSICIANS REPORT To be completed for all cases involving injury or illness (DO NOT USE ABBREVIATIONS) action against the (Use back if necessary) DIAGNOSIS AND TREATMENT person ling out , Received patient in Emergency Department after reported fall in husband s room. 12 cm x the incident report 12 cm ecchymotic area noted on right hip. X-rays negative for fracture. Good range of motion, and encourages J. Reynolds, MD no c/o pain. VAS 0/10. Ice pack applied. looking beyond the DISPOSITION sent home, written instructions provided incident to deterPERSON NOTIFIED OTHER THAN HOSPITAL PERSONNEL DATE TIME mine other factors. NAME AND ADDRESS R. Manning (daughter), address same as pt 3-20-09 1500 These factors may PHYSICIANS SIGNATURE DATE include orientation J. Reynolds, MD 3-20-09 and training, stafng ratios, and Guido GW. Legal Issues in Nursing. 4th ed. Stanford, CA: Appleton and Lange; 2005. other issues inuencing patient safety. LPN 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.

DESCRIPTION OF THE INCIDENT (WHO, WHAT, WHEN, WHERE, HOW, WHY) (Use back of form if necessary)

Selected references
Chart Smart: The A to Z Guide to Better Nursing Documentation. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 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.

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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