In a health care facility, such as a hospital, recovery center, nursing home, or assisted living, an incident report is a form that is filled out to record details of an unusual event that occurs at the facility, such as an injury to a patient or client.
Incident reports should not be used to blame or punish staff but rather to learn areas of concern and better client/patient safety approaches.
Incident Reports are used to communicate information to others and document significant events within individual records and as required by state standards. People often use the information obtained from incident reports when formulating plans or profiles, developing support strategies, and when making decisions.
Consequently, it is extremely important for the content of the Incident Report to reflect clear information in a factual, unbiased manner to avoid passing along opinions and judgments. What a staff person has to say concerning an incident is essential to other people who are trying to understand what has happened and why it occurred.
Staff should re-read the reports that they have written prior to submitting them to ensure that they are legible, have been completed properly and that the report truly states what the writer has intended to convey. All sections of the report must be completed (avoid leaving blanks). Incident Reports are legal documents that the individual may view, their guardian, designee, or legal representative, and may be utilized by courts. Be sure to use the full name of staff or providers when referencing them in a report; initials of staff/providers are not sufficient.
Staff should prepare an incident report to document unusual and/or significant events or emergencies involving individuals who receive services and/or support. Examples of such events include but are not limited to the following:
- Injury to an individual
- Aggressive behavior directed at others
- Self-abusive behavior
- Endangering or threatening others
- Serious illness and/or hospitalization
- Imminent death or death
- Property destruction
- Serious disruptive situation while in the community
- Illegal or unusual problematic behavior
- Being victimized by another individual who receives services
- Any incident involving the police, fire department, ambulance, etc.
- Any time someone has physically intervened with an individual when such intervention is not in accordance with an approved behavioral treatment plan
- Any time an individual is involved in an automobile accident while receiving services
- Being a victim of a crime reported to a law enforcement agency;
- Being incarcerated (in jail or prison for at least one overnight stay);
- Others should note significant accomplishments or other positive changes.
If you are unsure about whether or not to complete an incident report, complete one.
If an incident involves the behavior/injury of more than one individual, separate reports are necessary. Be sure that you do not include confidential information about others on an individual’s report.
First and most important, don’t delay. Obtain the proper documentation as soon as possible and fill out the details as clearly as you can remember. Make sure to outline:
-The name and address of the organization.
-The concern in one or two pages, including:
Who – Who was involved in the incident?
What – What exactly happened?
Where – Where did the situation occur?
How – How was the situation or event handled?
Safety – Also, remember, if the situation warrants it, implement a safety plan and note what you did to keep everyone safe.
Each person writing an Incident Report should consider the following:
Cause of Incident:
Make every attempt to provide only factual information. Even if the actual cause of an incident remains unknown after you have attempted to determine it, you should give as much information as you have concerning what happened before the event/during the event, as this may provide a clue to the reader. If you did not witness the incident or event, you might still write an Incident Report; however, be sure to state that the information is based on what was reported to you and by whom it was reported.
Describe the incident in concrete, behavioral terms. Do not use generalities…be specific. Review your report to verify that you have not used judgmental terminology or left unanswered questions. It is best to prepare an Incident Report immediately following the incident while the facts are still clear. However, staff may still be emotionally involved at that time, so it may be helpful to have another person review the report prior to it being submitted.
Please remember that your description of the incident is what other people will rely on to obtain information concerning the individual and the incident. It is important that your report does not convey negative images of you or the individual when a more neutral one should be conveyed. Examples: stating someone stole food out of the refrigerator when the individual took food out of the refrigerator. Your report has the ability to influence others, so it is important that it is properly prepared and provides a factual accounting of the incident.
Reliability of your observation:
Would other people seeing or hearing the incident agree with the account that you have written? If another person was involved in the incident or witnessed it, consult with that person to ensure that the report concurs with that person’s observations. When writing your report, use terms that are specific and clearly describe the behavior that occurred. For example, don’t use generalities such as aggressive/upset/agitated, state the behavior that you observed that made you believe the person was being aggressive, was upset, or agitated.
Objectivity: When writing your report, be sure that you have not allowed an earlier situation or prior information to influence your perception of the current incident. You are writing your report as a recorder, not as a judge. Consequently, be sure that your report is free from judgmental statements, sarcasm, or condescending comments.
California Rules and Regulations
California Code Regs. Tit. 22, § 87861 – Reporting Requirements
- Death of any resident from any cause.
- Any injury to any resident that requires medical treatment.
- The use of an Automated External Defibrillator.
- Any unusual incident or resident abuse that threatens the physical or emotional health or safety of any resident.
- Any suspected physical or psychological abuse of any resident.
- Communicable diseases, as specified in California Code of Regulations, Title 17, Section 2502.
- Fires or explosions which occur in or on the premises.
- Resident’s name, age, sex, and date of admission.
- Date and nature of event.
- Attending physician’s name, findings, and treatment, if any.
- Disposition of the case.
California Health And Safety Code Chapter 7 11830
Per California Code Chapter 7. Quality Assurance 11830 the telephonic and written reports of resident deaths occurring in a licensed facility that is required to be reported to the department should include, but not be limited to, a description of the event or incident, including the time, location, and nature of the event or incident, a list of immediate actions that were taken, including persons contacted, and a description of the followup action that is planned, including, but not limited to, steps taken to prevent a future death.
A telephonic report required which includes the event or incident and all information that is known at the time of the report, should be submitted to the department within one working day of the event or incident.
A written report which includes all information required should be submitted to the department within seven calendar days of the event or incident.
- In 1995, hospital-based surveillance was mandated by the Joint Commission because of the perception that incidents resulting in harm were frequently occurring. The Joint Commission employs the term sentinel event in lieu of a critical incident and defines it as follows:
- An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
- As one component of its Sentinel Event Policy, The Joint Commission created a Sentinel Event Database. The database accepts voluntary reports of sentinel events from member institutions, patients and families, and the press. The particulars of the reporting process are left to the member healthcare organizations. The Joint Commission also mandates that accredited hospitals perform root cause analysis of important sentinel events. Data on sentinel events are collated, analyzed, and shared through a Web site, an online publication, and its newsletter, Sentinel Event Perspectives.
- Your organization should have its form to use for incident reporting. If not, create one with the required information included:
- Organization Name
- Organization Address
- Reporters Name
- Incident Date
- Incident Narrative
The preferred method for submitting a patient safety concern to The Joint Commission is through our online submission form as it allows for more direct, timely receipt and review of your concerns.
- If you prefer to mail a report you can utilize this form.
Online: Submit an update to your incident (You must have your incident number)
- Mail: Office of Quality and Patient Safety
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181
By policy, The Joint Commission cannot accept copies of medical records, photos or billing invoices and other related personal information. These documents will be shredded upon receipt.
Patient safety is a priority. Documentation of patient care holds the healthcare team members to professional accountability and demonstrates the quality care you have given. When the unforeseen happens, and sometimes it does, the reporting of incidents can help identify will potential issues are. We need to focus on a blameless reporting atmosphere where healthcare providers feel safe making reports. Speak up if you have questions regarding your workplace or see areas of concern.