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, 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; the initials of staff/providers are insufficient.
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 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, 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, 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.
In accordance with TDMHSAS Licensure Administrative Rule 0940-5-2-.20, licensees must report to the Regional Licensure Office
any allegations or suspicion of abuse, dereliction, deficiency in the operation of the facility or service, or other critical incidents.
The following incidents must be reported to the Regional Licensure Office by the close of the next business day after the event or the next business day after the agency was made aware of the event:
- Death or suicide attempt of a service recipient who is a client of a residential facility or who is in the care or custody of a nonresidential licensed agency.
- Service recipient self-harm or an unsuccessful attempt to self-injure.
- Physical/verbal abuse or neglect of service recipient by staff, including acts of aggression, threats, and harassment, as well as intentional withholding of services or treatment and negligent failure to provide services or treatment.
- Sexual contact or inappropriate behavior between staff and service recipients
- All seclusion, mechanical or physical holding of a service recipient incidents resulting in death, serious injury, or suicide attempt of a service recipient AND seclusion and/or restraint incidents not administered according to agency policy. (See Licensure Administrative Rule Chapter 0940-3-9-.19.)
- A service recipient being absent from the grounds of a residential agency in violation of agency rules or guidelines, or the service recipient cannot be located on the grounds of a residential agency and is outside of direct supervision of staff for more than fifteen (15) minutes.
- Theft by the staff of service recipient’s personal items, including but not limited to money, medication, jewelry, clothing, etc., and improper use of client funds and unauthorized use of a client’s bank accounts and debit, credit, or EBT cards.
- Injury to service recipient that requires a visit to ER/walk-in clinic for evaluation/treatment or more than basic first aid by facility staff. “Basic first aid” is defined, for the purposes of these instructions, as minor medical assistance rendered to a service recipient such as the application of a Band-Aid, application of antiseptic or anti-itch cream, application of a cold or heat compress, or a compression bandage, or issuance of aspirin, naproxen sodium, ibuprofen or other over-the-counter pain medication.
- Damage to the agency’s equipment or property, including, but not limited to, broken windows, doors, and floors, impacts the ability of the agency to provide services or impacts the living conditions of the residents, or the ability of clients to receive services. This includes structural problems due to fire, flood, etc. This also includes, but is not limited to, damage exceeding $250 caused by physical aggression by a service recipient.
- Deficient facility conditions such as an infestation of rodents, insects, or pests, including lice or bed bugs, OR loss of heating, air conditioning, water, sewer/septic system, gas, or electric service in a facility for more than 8 hours
The following DO NOT need to be reported to the Regional Licensure Offices:
- Service recipient grievances regarding the quality of service at the facility. “Quality of service” issues include but are not limited to incidents involving a client’s dislike of food served, dislike of homework assigned, inability to access telephone or television after posted curfew, and other similar issues. These are best addressed through an agency’s grievance procedures. Pursuant to Tennessee Administrative Rule 0940-5-6-.06(1)(a), agencies must notify clients of the facility’s grievance procedure and a copy of all of the agency’s rules and regulations.
- Physical (or verbal) aggression between service recipients, if no physical injury to a service recipient.
- Staff-only injuries, staff relationships with other staff, or staff misconduct that does not involve a client or when not on duty, i.e., DUI
- Service recipient dental and medical appointments such as annual, wellness, and follow-up visit for conditions for which the patient has been seen and is currently being monitored by a physician.
- Medical incidents that are not a result of an injury/accident are not reportable. Medical incidents include but are not limited to ER visits due to headaches, stomach aches, fever, elevated blood pressure, and psychiatric episodes requiring mobile crisis evaluation and/or inpatient psychiatric hospitalization. Please note that although these types of incidents are not reportable, documentation must be maintained on how each situation was handled.
*The above list is not all-inclusive. Contact your Regional Licensure Office if clarification is needed. Regional offices are listed on the Reportable Incident Form below.
Facilities must use a Reportable Incident Form (attached here and copied 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 of 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.