In a healthcare facility, such as a hospital, recovery center, nursing home, or assisted living, an incident report is a form 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 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, as required by state standards. People often use the information from incident reports when formulating plans or profiles, developing support strategies, and making decisions.
Consequently, the content of the Incident Report needs 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 others trying to understand what has happened and why it occurred.
Staff should re-read the reports they have written before submitting them to ensure that they are legible, have been completed correctly and that the report honestly states what the writer 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; the initials of staff/providers are insufficient.
Staff should prepare an incident report to document unusual or significant events or emergencies involving individuals who receive services 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
- Severe illness and 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 whether to complete an incident report, complete one.
If an incident involves the behavior/injury of more than one individual, separate reports are necessary. Ensure 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 following:
-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, 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 before it is 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. Your report mustn’t convey negative images of you or the individual when a more neutral one should be given. Examples: stating someone stole food from the refrigerator when the individual took food out of the fridge. Your report can influence others, so it must be adequately prepared and provides a factual accounting of the incident.
Reliability of your observation:
Would other people seeing or hearing the incident agree with your written account? 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 specific terms and clearly describe the behavior that occurred. For example, don’t use generalities such as aggressive/upset/agitated; state the behavior you observed that made you believe the person was aggressive, upset, or agitated.
Objectivity: When writing your report, be sure 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, ensure your report is free from judgmental statements, sarcasm, or condescending comments.
Delaware Code Title 16-Health and Safety Chapter 51 Subchapter V Mental Health Patients’ Bill of Rights § 5162 Notification of critical incidents and deaths, report forms explores what needs to be reported, when, and how. Please note the complete code is at the bottom of this lesson.
Per the code, a hospital or residential center must report the following:
- Critical incidents
Critical Incidents include:
- Attempted suicide
- Seclusion exceeding 15 minutes
- Physical restraint exceeding 5 minutes or involving injury
- Victimization prompts solicitation of police intervention or investigation.
When a death occurs:
Notwithstanding any other provision of law, each covered facility should notify the protection and advocacy agency in writing or electronically within 72 hours of all critical incidents and, upon request, facilitate protection and advocacy agency contact with the patient, resident, or authorized representative of the patient or resident.
In addition, notwithstanding any other provision of law, each covered facility should notify the protection and advocacy agency within 72 hours of the date of any patient or resident death. Such notice should include the following:
- brief identifying information
- contact information for the next of kin
- administrator, or estate executor
- age of the patient or resident
- condition of the patient’s or resident’s health before death
- the apparent cause of death
No person or covered facility should be liable in any civil action because of the provision of notice of a critical incident or death to the protection and advocacy agency in conformity with this section.
Each covered facility should cooperate with the protection and advocacy agency’s assessment or investigation of a critical incident or death. In furtherance of this duty, no covered facility shall discharge, discriminate, or retaliate against any person who provides the protection and advocacy agency with information or assistance in assessing or investigating a critical incident or death.
Title 16 states that hospitals must report all significant adverse incidents involving a patient to the Department within ten calendar days.
A significant adverse incident is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient. The Department shall define “major adverse incident” and provide further clarification in regulation.
The hospital must investigate major adverse incidents.
A summary of the hospital’s investigative findings will be forwarded to the Department within a timeframe agreeable to both parties.
Hospitals must notify the Department immediately of any event occurring within the hospital that jeopardizes the health or safety of patients or employees, including:
(1) An unscheduled interruption for three or more hours of the physical plant or clinical services impacts patients’ or employees’ health or safety.
(2) A fire, disaster, or accident results in the evacuation of patients from the hospital.
(3) An alleged or suspected crime that endangers the life or safety of patients or employees, which is also reportable to the police department, and which results in an immediate on-site investigation by the police.
(c) Information submitted as a significant adverse incident is considered peer review information and not subject to public disclosure except as aggregate data.
- 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 instead 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” has any process variation for which a recurrence would carry a significant chance of a severe adverse outcome.
- The Joint Commission created a Sentinel Event Database as one component of its Sentinel Event Policy. 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 a 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, billing invoices, or other related personal information. These documents will be shredded upon receipt.
Patient safety is a priority, and patient care documentation holds the healthcare team members to professional accountability and demonstrates the quality of care you have given. When the unforeseen happens, and sometimes it does, reporting incidents can help identify potential issues. We must 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.
§ 6500.20. Incident report and investigation.
(a) The agency and the home shall report the following incidents, alleged incidents, and suspected incidents through the Department’s information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
(2) A physical act by an individual in an attempt to complete suicide.
(3) Inpatient admission to a hospital.
(4) Abuse, including abuse to an individual by another individual.
(7) An individual who is missing for more than 24 hours could be in jeopardy if missing at any time.
(8) Law enforcement activity that occurs during the service provision or for which the individual is the subject of a law enforcement investigation may lead to criminal charges against the individual.
(9) Injury requiring treatment beyond first aid.
(10) Fire requiring the services of the fire department. This provision does not include false alarms.
(11) Emergency closure.
(12) Theft or misuse of individual funds.
(13) A violation of individual rights.
(b) The agency and the home shall report the following incidents, alleged incidents, and suspected incidents through the Department’s information management system or on a form specified by the department within 72 hours of discovery by a staff person:
(1) Use of a restraint.
(2) A medication error as specified in § 6500.137 (relating to medication errors) if a health care practitioner ordered the medication.
(c) The individual and persons designated by the individual shall be notified within 24 hours of discovering an incident relating to the individual.
(d) Documentation of the notification in subsection (c) shall be kept.
(e) The incident report, or a summary of the incident, the findings, and the actions taken, redacted to exclude information about another individual and the reporter, unless the reporter is the individual who receives the report, shall be available to the individual and persons designated by the individual, upon request.
(f) Immediate action shall be taken to protect the individual’s health, safety, and well-being following the initial knowledge or notice of an incident, alleged incident, or suspected incident.
(g) An investigation of an alleged or suspected incident shall be initiated within 24 hours of discovery by a staff person.
(h) A Department-certified incident investigator shall investigate the following incidents:
(1) Death that occurs during the provision of service.
(2) Inpatient admission to a hospital as a result of an accidental or unexplained injury or an injury caused by a staff person, another individual, or during the use of a restraint.
(3) Abuse, including abuse to an individual by another individual.
(6) Injury requiring treatment beyond first aid as a result of an accidental or unexplained injury or an injury caused by a staff person, another individual, or during the use of a restraint.
(7) Theft or misuse of individual funds.
(8) A violation of individual rights.
(i) The incident report shall be finalized through the Department’s information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the agency or home notifies the Department in writing that an extension is necessary and the reason for the extension.
(j) The following information shall be provided to the Department as part of the final incident report:
(1) Additional detail about the incident.
(2) The results of the incident investigation.
(3) Action is taken to protect the individual’s health, safety, and well-being.
(4) A description of the corrective action taken in response to an incident and to prevent the recurrence of the incident.
(5) The person responsible for implementing the corrective action.
(6) The date the corrective action was implemented or is to be implemented.
The provisions of this § 6500.20 amended under sections 201(2), 403(b), 403.1(a) and (b), Articles IX and X of the Human Services Code (62 P.S. § § 201(2), 403(b), 403.1(a) and (b), 901—922 and 1001—1088); and section 201(2) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4201(2)).
The provisions of this § 6500.20 amended June 17, 2016, effective June 18, 2016, 46 Pa.B. 3177; amended October 4, 2019, effective in 120 days, 49 Pa.B. 5777. Immediately preceding text appears on serial pages (382012) to (382013).
This section is cited in 55 Pa. Code § 6000.903 (relating to licensing applicability); and 55 Pa. Code § 6500.137 (relating to medication errors).