How to Write a Nurse Incident Report

If you dread writing incident reports, you might take comfort in knowing that you’re not alone. Stressing over getting the report done or about what to include are common concerns for nurses — not to mention worrying about whether filing the report reflects badly on your performance. Mistakes happen all the time, and healthcare facilities are not immune. According to a 2016 study conducted by Johns Hopkins, medical errors have become the third-leading cause of death in the U.S. and threaten the safety and well-being of patients. As time-consuming as incident reports may be, their role in patient care cannot be ignored.

What Is an Incident Report?

An incident report is an electronic or paper document that provides a detailed, written account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting. The incident doesn’t have to have caused harm to a patient, employee, or visitor, but it’s classified as an “incident” because it threatens patient safety.

To ensure the details are as accurate as possible, incident reports should be completed within 24 hours by whomever witnessed the incident. If the incident wasn’t observed (e.g., a patient slipped, fell, and got up on his own), then the first person who was notified should submit it. For the most part, these incident reports are completed by nurses or other licensed personnel and are used for risk management, quality assurance, educational, and legal purposes.

What’s the Purpose of an Incident Report?

Incident reports are used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for the following purposes:

1. Risk management. Incident report data is used to identify and eliminate potential risks necessary to prevent future mistakes. For example, if an incident report review finds that most medical errors occur during shift changes, risk management teams may suggest that nursing staff develop standardized turnover protocols to avoid future errors.
2. Quality assurance. Quality assurance is all about patient safety, customer satisfaction, and improving healthcare quality. Quality control groups comb through incident reports to look for indicators that suggest a patient received high-quality, patient-centered care at a reasonable price.
3. Educational tools. Incident reports make great training tools because everyone has an innate ability to learn from their mistakes — or the mistakes of others. Healthcare teams often use resolved incident reports as educational tools to prevent similar occurrences.

Be aware that because incident reports could potentially be used for legal purposes, providing incomplete, inaccurate, or false documentation in an incident report can harm patients and jeopardize the defense of any case — including your own.

What Classifies as an ‘Incident’ That Would Prompt a Report?

In most circumstances, nurses are required to complete an incident report whenever they witness a reportable event or are notified that one has occurred. What constitutes a reportable event may vary by organization and practice setting, but the New York State Department of Health has identified some of the most common types:

• Unexpected events related to prescribed medications and/or treatments
  • Examples: adverse reactions, equipment failure or misuse, medication errors
• Bodily injury
  • Examples: assaults, burns, falls, needle sticks
• Patient-related occurrences
  • Examples: complaints, elopement (i.e., the patient leaves without authorization), treatment refusal
• Near misses
  • Example: potential for an error existed but was corrected before it occurred

Consider the following examples as situations in which an incident report should be filed:

1. You’re working as a nurse on an acute inpatient psych unit when one of the patients begins to act violently and attacks a staff member or another patient.
2. You’re ambulating a patient in the hallway and securely holding onto their gait belt when the patient abruptly falls to their knees before you had a chance to react.
3. You’re interviewing a clinic patient who passes out and falls from the examination table onto the floor without warning. Upon awakening, the patient appears to be fine but passes out again a few minutes later. Emergency medical services are called to respond.

What Information Do You Put in an Incident Report?

According to RegisteredNursing.org, the information in an incident report should always include the who, what, when, where, and how, and — at the very least — the following pertinent information:

• Date, time, and facility location
• Where the incident occurred
• Incident type
• Name of the person(s) affected by the incident
• Witnesses or names and titles of other involved persons
• Written summary of what happened, which can include:
  • Detailed description of the event with events listed chronologically
  • Witnesses or injured party statements
  • Injuries sustained by the person(s) as a result of the incident or the outcome
  • Actions taken immediately after the incident occurred
  • Treatments administered
  • Contributing factors
• Name(s) of who was notified (i.e., doctor, supervisor)
• Recommendations for change to prevent future incidents

Incident reports come in several formats. Typical incident report form examples include clinical events and employee-related work injuries.

6 Tips for Writing an Effective Incident Report

Now that we know how important these incident reports are, here are six tips to consider to make sure you write a detailed and effective report, as outlined by healthcare regulation and compliance company HCPro.

Tip #1: Make sure it is clear, concise, and accurate.

Tip #2: Use proper grammar, punctuation, and spelling.

Tip #3: State facts objectively and avoid making assumptions or casting blame.

For example:

• Write this: “The patient, who typically uses a cane, was walking down the hall when he slipped on the wet floor. The patient was not using his cane at the time of the fall.”
• Not this: “The patient was walking too fast down the hall and slipped. He should have been using his cane.”

Tip #4: Provide a chronological sequence of events.

For example:

• 12:05, Rob from Environmental Services finished mopping the floor. A “Caution: Slippery When Wet” sign was displayed.
• 12:15, Simon fell on the floor.
• 12:15, Nurses were called.
• 12:16, Charge nurse Mary arrived first and assessed the patient.

Tip #5: Include direct quotations made by witnesses or the injured party, if applicable.

Provide full names of these witnesses in case they are needed later.

Tip #6: Start the writing process early or take notes shortly after to remember key details.

Evernote is recognized as one of the best note-taking apps for healthcare providers. Microsoft OneNote, Notability, and Simplenote are good options, as well.

Organizational and practice setting requirements may vary. Regardless of your nursing background, or whether you’re working at a hospital, clinic, or other healthcare center, it’s your responsibility to follow the incident reporting guidelines established by your facility.

Image courtesy of iStock.com/Shuttermon