Cart
Courses: 0

Total: $00.00

Incident Reporting Pennsylvania 20-22211 1 Hour Back to Course Index

 

 


    

INCIDENT REPORTING

 

 

  

Introduction

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.

images-2What is the Purpose of an Incident Report?

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.

imgres-7When Should An Incident Report Be Written?

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:

imgres-1

 

 

 

  • 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.

images-1Writing an Incident 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?

When – When did the event occur; note the specific date and time.imgres-5

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.

Language:

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.

 

imgres-9Pennsylvania Administrative Code Regarding Incident Reporting 

Pennsylvania. Admin. Code § 6500.20 states that an agency should report the following incidents, alleged incidents, and suspected incidents through the Department’s information management system or on a form specified by the Department. Please note the full code is at the bottom of this lesson.

 

The incidents that require a report within 24 hours of discovery by a staff person include:

  • Death
  • A physical act by an individual in an attempt to complete suicide
  • Inpatient admission to a hospital
  • Abuse, including abuse to an individual by another individual
  • Neglect
  • Exploitation
  • An individual who is missing for more than 24 hours or who could be in jeopardy if missing for any period of time. 
  • Law enforcement activity that occurs during the provision of a service or for which the individual is the subject of a law enforcement investigation that may lead to criminal charges against the individual
  • Injury requiring treatment beyond first aid
  • Fire requiring the services of the fire department. This provision does not include false alarms
  • Emergency closure
  •  Theft or misuse of individual funds
  •  A violation of individual rights

 

The incidents that require a report within 72 hours of discovery by a staff person include:

  • Use of a restraint.
  • A medication error as specified in §  6500.137 (relating to medication errors), if the medication was ordered by a health care practitioner.

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

 

An investigation of an incident, alleged incident or suspected incident shall be initiated within 24 hours of discovery by a staff person\

A Department-certified incident investigator will conduct the investigation of the following incidents:

  • Death that occurs during the provision of service
  • 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
  • Abuse, including abuse to an individual by another individual
  • Neglect
  • Exploitation
  • 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
  • Theft or misuse of individual funds
  • A violation of individual rights

The incident report should 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.

The following information should be provided to the Department as part of the final incident report:

  • Additional detail about the incident.
  • The results of the incident investigation.
  • Action taken to protect the health, safety, and well-being of the individual.
  • A description of the corrective action taken in response to an incident and to prevent recurrence of the incident.
  • The person who is responsible for implementing the corrective action.
  • The date the corrective action was implemented or is to be implemented.

images-9The Joint Commission on the Accreditation of Healthcare Organizations

  • 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.

images-10How Do You Submit An Incident Report

  • 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.

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.

 

Conclusion

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.

§ 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:

   (1)  Death.

   (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.

   (5)  Neglect.

   (6)  Exploitation.

   (7)  An individual who is missing for more than 24 hours or who could be in jeopardy if missing for any period of time.  

   (8)  Law enforcement activity that occurs during the provision of a service or for which the individual is the subject of a law enforcement investigation that 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 the medication was ordered by a health care practitioner.

 (c)  The individual and persons designated by the individual shall be notified within 24 hours of discovery of 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 health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.

 (g)  An investigation of an incident, alleged incident or suspected incident shall be initiated within 24 hours of discovery by a staff person.

 (h)  A Department-certified incident investigator shall conduct the investigation of 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.

   (4)  Neglect.

   (5)  Exploitation.

   (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 taken to protect the health, safety and well-being of the individual.

   (4)  A description of the corrective action taken in response to an incident and to prevent 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.

Authority

   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)).

Source

   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 at serial pages (382012) to (382013).

Cross References

   This section cited in 55 Pa. Code §  6000.903 (relating to licensing applicability); and 55 Pa. Code §  6500.137 (relating to medication errors).