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 in order 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 approaches to client/patient safety.
Incident Reports are used to communicate information to other people and to 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, to develop 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.
Healthcare Facility Regulation (HFR), a division of the Department of Community Health (DCH), is responsible for health care planning, licensing, certification, and oversight of various health care facilities and services in Georgia. Programs must submit to the Georgia Department of Community Health electronically or by facsimile a report, in a format acceptable to the department, within 24 hours whenever the program becomes aware of an incident that results in injury to a client requiring medical treatment beyond first aid that is received by a client as a result of or in connection with any emergency safety intervention. Examples of incidents that should be reported:
- Serious injury which causes any significant impairment of the physical condition of the resident as determined by qualified medical personnel. This includes, but is not limited to burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else;
- Injuries of unknown source
- Suicide Attempts
- Exploitation/Misappropriation of resident property or funds.
- Emergency safety interventions resulting in any injury of a patient requiring medical treatment beyond first aid
- Elopements when the patient cannot be located within twenty-four (24) hours or where there are circumstances that place the health, safety, or welfare of the patient or others at risk; or
- Any incident which results in any federal, state, or private legal action by or against the facility which affects any patient or the conduct of the facility
Reports can be made online here. The form that is required looks like this:
Facilities must use a Reportable Incident Form (attached here and copy and pasted below) to notify the respective Regional Licensure Office of incidents that occur at a TDMHSAS licensed facility or service. Along with the Incident Form, you must send all pertinent attachments that may aid in investigating the 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.
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.