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What Is an Incident Report?

What’s the purpose of an incident report, what classifies as an ‘incident’ that would prompt a report, what information do you put in an incident report, 6 tips for writing an effective incident report, how to write a nurse incident report.

Jul 24, 2024

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.

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 .

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:

• 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.
• 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.
• 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.

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:

• Examples: adverse reactions, equipment failure or misuse, medication errors
• Examples: assaults, burns, falls, needle sticks
• Examples: complaints, elopement (i.e., the patient leaves without authorization), treatment refusal
• 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:

• 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.
• 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.
• 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.

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
• 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 .

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.

• 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 One N ote , 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

Last updated on Jul 24, 2024. Originally published on Nov 30, 2018.

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Nichole L. Cosgrove, MSN, APRN, FNP-C is a contributing writer for Berxi. She is a family nurse practitioner currently specializing in pain management with a background in mental health nursing and a recreational medical freelance writer. Nichole lives in rural Nebraska with her husband, teenage son, and their family cat, and they have an “adopted” daughter who lives in Germany that they welcomed into their family when she was a visiting exchange student. She loves Husker football, Chicago Cubs baseball, and movies with thriller and horror genres being her favorite.

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Nursing Incident Report | A Quick Guide

Did you know that one of the risks to patient safety is unexpected and preventable incidents? Patient safety is the number one priority of any healthcare facility. One of the ways of ensuring this is by writing a nursing incident report– a document that not only identifies issues but also provides opportunities for improvement. Incident reporting is strictly based on learning from prior experiences. For this reason, you must learn how to write a good nursing incident report. With the help of our nursing writers , creating a compelling incident report is easy. In this guide, our nursing writers will provide you with all the steps and tips needed to learn how to write an incident report.

What is the Meaning of an Incident Report?

An incident report is a type of document that systematically outlines important details about an unexpected event or accident. Nurses write an incident report to report an incident that could have or did cause harm to a patient or property damage within healthcare.

So when should an incident report be filed? An incident report is filed whenever any of the following incidents occur:

• Medication errors : Any errors that occur when prescribing or administering medication should be recorded. Medical errors could also occur because of wrong dosage, wrong medication, incorrect route of administration, and giving medication to the wrong patient.
• Malfunction of a medical device : When a medical device fails to function properly, especially when in use, it must be reported.
• Patient falls: Incidents of either patient falling either in the hospital or under the care of a nurse, at home or at a nursing home must be reported.
• Fire: If a fire occurs in the facility, then it must be reported.
• Adverse drug reactions: Unexpected reactions to a medication given to patients must be reported.
• Bedsores: Bedridden patients or those with limited mobility who develop pressure ulcers should be reported.
• When a patient leaves the hospital against medical advice: If there are instances when patients walk out of the hospital without being formally discharged or refusing to continue to receive treatment, then it should be reported.
• Near misses or close calls: In the event that an incident occurs but was prevented before affecting the safety of the patient, it should also be reported.
• Disease outbreaks: Disease outbreaks within healthcare settings should be reported.

What are the Elements of an Incident Report?

The following elements should be included in your nursing incident report:

• Date, time, and location where the incident happened. This helps establish a timeline for the events that happen.
• Name and address of the facility where the incident occurred.
• Names of the affected individuals
• Names and roles of witnesses of the incidents,
• Incident type and details, written in a chronological format
• Key details of the injury or damage.
• Total cost of the injury and damage.
• Name of physician notified.
• Suggestions for corrective action to prevent such incidents in the future.

The aim is to provide as much information as possible to ensure that readers understand exactly what happened. It will also help the management team set up appropriate measures to ensure such incidents do not occur again.

When Should an Incident Report be filed?

Incident reports are written in the hospital immediately after an incident occurs and not later than 48 hours. The rule of thumb is immediately an incident occurs. Even if it does not result in harm, the facility or organization will still have something to learn from it. If you are not sure whether to write an incident report, consult your facility's policy or, better yet, write it whenever something unusual happens.

A nurse or any other licensed professional present when the incident occurs is responsible for filing an incident report.

Importance of Incident Reporting

An incident report is an essential part of an organization's safety measures and quality improvement. As a nurse, you must write an incident report every time an abnormal incident occurs. Here are more reasons why nursing incident reporting is mainly for:

Maintain Patient Safety

The World Health Organization (WHO) defines patient safety as the absence of preventable harm to patients while receiving care at a healthcare facility. Maintaining the safety of patients is the sole responsibility of a healthcare facility, and one of the ways of ensuring this is by writing an incident report.

By documenting incidents, an organization can implement corrective measures to ensure they do not occur again in the future, thus safeguarding patient safety.

Quality Improvement

Incident reports provide valuable information that can help with quality improvement initiatives within an organization. The safety of patients can be improved when an organization engages in a cycle of quality improvement.

An analysis of the incident will reveal significant problems and areas for improvement, such as staff training, implementing evidence-based practices, increasing communication, etc. This approach ensures that an organization keeps its patients and workers safe from harm. 

Track Trends

A well-written incident report helps an organization identify a pattern of problems or issues that are recurring that could jeopardize the safety of everyone within. These trends may indicate a larger problem within an organization, thus allowing the management to adopt preventive measures.

Additionally, by tracking trends, an organization can gain foresight about patient experiences and improve the quality of services.

Help with Risk Management

Incident reports are great tools in the risk management process. When an organization is able to identify problems and near misses, it can design strategies to curb liabilities and prevent serious problems.

Effective risk management strategies are based on accurate information from incident reports, thus helping minimize legal, financial, and reputation risks that could damage an organization.

Professional Accountability

Writing incident reports promotes accountability among nurses and other healthcare workers. By documenting their actions and behaviors when an incident occurs, healthcare workers can take responsibility for their actions and seek improvement.

By taking accountability, nurses and other employees can promote a culture of continuous improvement and growth.

Legal Compliance

An incident report serves as a record for liability. The report includes crucial information about an incident, how it happened, and those affected. Healthcare workers are bound by legal and regulatory requirements when writing this information to demonstrate their commitment to ensuring patient safety and accountability.

Remember that incident reports could be used by authorities and the court when investigating the cause of the incident. If it is properly written, an incident report can provide valuable evidence that will prove the nurse and the facility is not at fault for the incident.

Failure to report these incidents or misrepresent them results in serious legal issues for both the organization and its workers.

Steps for Writing a Nurse Incident Report

Follow these steps to help you write an effective nursing incident report.

Gather Information

Gather all relevant information about the incident, such as the time, date, location where the event occurred, and who was affected or witnessed the event, e.g., patients, healthcare providers, etc.

Use the following questions to help you know what information to include in your report:

• What type of injury occurred? Was it fatal or non-fatal?
• What were the employees/patients doing when the incident happened?
• Who asked the employee or the patient to do what they were doing at the time of the incident?
• Was property (s) damaged?
• Where did the incident happen?

Remember, incident reports are done as part of the process of analyzing a particular event that has led to an injury, property damage or the presence of a hazard. So, providing adequate information about an issue can help ensure that proper measures are put in place to prevent the situation from happening again in the future.

Always ensure that your incident report reflects what happened exactly. So, ensure you take time to remember everything before writing the report.

Describe What Happened

Now that you remember everything that happened, begin writing it. Provide a chronological order of the events leading up to the incident. Provide the time and date the incident occurred to establish a clear timeline of the events and uncover any trends.

Consistent and comprehensive information about the time will help investigators track, report, and analyze the events of what happened. In addition, it will help establish the duration of the incident, response time, and actions taken at the time of the incident.

If the event was a medical error, provide information on the type of medication, brand name, manufacturer, and the nature of the error that occurred.

Also, provide the location of the incident. The building, room, floor area, etc. Use visual aids, such as a picture, to ensure your information is more precise. This information is necessary to identify surrounding risks that could have caused the problem.

Use clear and objective language and ensure every piece of information is relevant to the event.

Describe the Injuries

Determine the outcome of the incident. If people were injured, write down the nature of those injuries and provide the following details:

• Type of injury
• The severity of the injury
• Injured body parts.
• Type of treatment(s) provided.

Write down Patient’s or Affected Person’s Information

Document all relevant information about the patient involved in the incident. Provide accurate information such as their names, ages, medical record number, bed number, illness, condition before and after the incident, etc.

Keep in mind that patient information must be handled with confidentiality . Follow your organization’s privacy policies and regulations when sharing such information in the incident report. Ensure that no unauthorized persons access this information.

If other people were affected, identify them with their names, job titles, shift arrangements, training, contact numbers, and any other relevant information that will help those involved make important decisions.

Related: Ethical dilemmas in nursing.

Identify the Witnesses

The people present during the incident are most helpful when providing accurate information about events. These witnesses are an important part of any incident as they help clarify what happened and provide a sequence of the events that resulted in the incident.

So, identify the wiriness in the incident by naming them, their titles and roles at the time the incident happened.

Once you identify them, record their accounts of every incident that occurred. Please note witnesses directly involved in the incident, particularly serious issues, could be experiencing emotional stress. Therefore, they could need time to calm down first before talking about what happened.

Ensure you conduct the interview as soon as it has happened. This ensures the witnesses’ recollection of the events is fresh. Having this ensures detailed and accurate information that will smoothen the investigation process.

Objectivity is key when it comes to taking witnesses into account. Ensure you record their accounts of the incident verbatim.

Write Down Contributing Factors

What contributed to the incident? Was it the weather? Equipment failure? Was it hazardous substances? Human error? Whatever it is that you think led to the incident happening, write it down clearly.

Document both immediate factors and underlying issues to ensure effective and lasting solutions to the problem. It is important to clearly state which factors happened after the incident and those that contributed to the issues. This clarity will help the management team to design effective strategies to solve the problem.

Please also note that there is never one single cause of an issue. Identify all variables that contributed to the incident, even those that you think were insignificant. Make sure to look deeply, without judgment, at everyone's actions and irresponsibility when the incident happened.

Document the Actions Taken

Were there actions taken to stop the incident from going on? Record all actions and interventions taken to help those affected by the incident in the action section. Were they given medications? Was the equipment repaired?

Provide specific tasks of everything that was done to curb the event. Write these actions in the sequence in which they were taken. As you do this, ask yourself the flowing questions:

• Why was it okay for them to make the decisions they did?
• Why did they act the way they did?

Also, mention whether the facility's management or authorities were notified. If possible, provide details of conversations, consultations, or referrals that occurred because of the incident.

Consider also including the specific actions that you can take to complete writing the incident report.

Recommendation for Future

What would you like done in the future? Document your suggestions that will help prevent similar incidents in the future based on what you have learned now. For instance, if a patient or staff fell and injures themselves because of a slippery floor, suggest covering them with mats and rugs or using scrubbers-dryers instead of wet cleaning.

Besides specific strategies, you can propose improvements in the facility's policies, procedures, and training to mitigate risks.

Review and Revise the Incident Report

Go through your incident and check whether you have included all the information. Check for accuracy, completeness, and consistency throughout the document. If possible, verify your information with your coworkers or other witnesses to ensure your document reflects the true nature of the incident.

Consider also verifying your incident report against medical records or other hospital documentation to ensure you have written it according to the facility's policy.

Do's and Don't for Writing an Incident Report in Nursing

• Write your incident report immediately after it has happened.
• Your description of what happened should be clear and concise.
• Provide a detailed timeline of the events and the actions.
• Provide the interventions that were done to help the injured person.
• If there were any witnesses present, include direct quotes of their account.
• Write with a pen, not a pencil. A pencil can be erased easily.
• Where possible, attach relevant photos of the incident, injury, etc., as they can help provide the root cause of the problem.
• Include the information about the incident report in a patient's health records.
• Procrastinate writing the report as this could lead to inaccuracy.
• Speculate or guess about what might have happened in the incident. Every information you provide should be factual.
• Use bias or judgmental language when describing the events.
• Refrain from throwing around accusations or blaming people for the actions that led to the incident. Instead, focus on identifying the main cause of the issues.
• Exaggerate or minimize the severity of the issue. Maintain honesty when reporting the facts of the incident.
• Dismiss near misses. Even when the incident did not result in loss of life or any form of harm, ensure you report it. Near misses provide valuable opportunities for people to learn and the organization to set measures to prevent future incidents.
• Forgetting to follow up. After submitting your incident report, follow up with the relevant parties to ensure appropriate actions are taken to prevent similar situations in the future. Ensure you advocate for the right changes, including policy changes.
• How to write a nursing Quality Improvement Report.
• Steps for writing a great policy analysis paper.
• How to write a nursing research paper.
• Writing a nursing interview essay.

And there you have it, a simplified guide for writing a nursing incident report the right way. Remember, when writing these types of reports, the aim is to capture every detail of the event so that someone who was not present or witnessed the events has a clear picture of what occurred.

If you are having a hard time writing an incident report, let our writers help you . Our expert writers will guide you on the dos and don’ts of writing a catchy incident report that leads to meaningful change.

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• Incident Report in Nursing: Definition and Examples

Nursing Career Guide

Why Incident Reports Are So Important for Nurses

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable,” states Professor Liam Donaldson, World Health Organization (WHO) Envoy for Patient Safety.

Two words: Incident Reports. Ask any nurse about them and you will probably not get a happy response. Groans about the time they take, uncertainty about what to include, and worries about being punished. Maybe even a little desire to skip it.

It’s time to rethink how you feel about incident reports. Stop seeing them as a time-sucking enemy. Start seeing them as a way to a better workplace…and your protection.

What exactly are they?

The definition is simple: An incident report in nursing is a report which details an event where a person is injured, or property is damaged, threatening patient, visitor, or staff safety. Although this seems straightforward, an “event” isn’t always obvious.

There are three types to know about:

Sentinel Event: Any unanticipated event in a healthcare setting that results in death, or serious physical or psychological injury to a patient, staff member, or visitor. If the event involves a patient, it is not related to the natural course of the patient’s condition.

These are the events that are clear-cut: A fatal medication error; a nurse is attacked and beaten by a patient; an infant is abducted from the nursery.

Minor Event: An inaccurate name for this type of incident report, this is any unplanned event that results in an injury or property damage, no matter how insignificant it seems.

Examples: A patient trips on their IV pole; a nurse cuts their finger while opening a vial; a wheel on the medication cart is broken.

Near-Miss: Unplanned events where no one was injured or property was damaged, but with a different action, position, or time, they could have been.

Examples: The nurse realizes they are about administer the wrong medication; a housekeeper mops up a spill and forgets to place a caution sign; a smeared label on a specimen is difficult to read.

Why are they important?

Although incident reports can take time in your already busy shift, they serve some important purposes:

• They protect YOU. Every nurse makes mistakes . When it happens, a well-documented incident report can actually save your nursing license and career. (Read Protecting Your Nursing License: Learn Why Nurses Lose Their Licenses and What to Do About It ) If you are ever named in a lawsuit, the first question a lawyer will ask is, “Did you complete an incident report?” Keep this in mind the next time you want to complain about the hassle of filling out that form.
• They protect your organization. If a patient or their family decides to file a lawsuit against the organization (which can also include you), it will be essential for the organization to show that policies were followed, an incident report was filed, and appropriate departments or people were notified.
• They result in better patient care and an improved work environment. It might not seem like your simple incident report will have much impact, but it does. The only way changes can happen is if safety and operations managers recognize the need to make things safer for everyone.
• They create a “reporting culture” that encourages staff to participate. One of the Joint Commission’s efforts is to get accredited members to educate all employees on how to report unsafe practices and conditions. Other industries, such as aerospace, have implemented “good catch” programs to remove the fear of reprisal when reporting hazards, especially near-misses (no-harm) events.
• They make restitution easier. Suppose a visitor’s coat is stolen or someone breaks into your locker and takes your wallet. Hospitals and organizations have incidents—large and small—every day. Without an incident report, it’s impossible for administration to be fair and accurate in providing compensation for injury, loss, or damage.

What is ideally included?

Workplaces have either designated software or a specific form to complete an incident report. These make it easy to include the necessary components of the report. Your documentation will provide every detail, written in a professional and objective style.

Here is the “Baker’s Dozen” of elements in a perfect incident report:

Administrative Information

• Your name and title
• Date and time of the incident
• Exact location of the incident

Incident Information

• Details of the events leading up to the accident
• Description of the incident, in chronological order
• Description of all injuries and/or damage

Witness Information

• Current observations about the incident area
• Witness full names and contact information
• Witness statements

Actions and Recommendations

• Actions that you took to give aid
• Actions that you took to prevent further injury/damage
• Recommendations to prevent another event

Final Section

• Documentation finalization and sign-off

What else should you know?

The incident report itself is very straightforward. However, it can be challenging to provide the necessary details in an objective manner; it’s tempting to make assumptions or place blame, especially away from ourselves.

Here are some tips from legal professionals. (Read Professional Liability Insurance for Nurses: Why EVERY Nurse Must Have It )

• An incident report should be filed for ANY unexpected event. Period. Years can pass between the time of the event and when a lawsuit is filed. You will never remember all the details, so recording them in real time—and separate from the medical record—can make all the difference in the outcome.
• Remember that the patient’s medical record does NOT include mention of the incident report. The report belongs to risk management or administration. If it becomes part of the medical record, the patient’s lawyers can argue that it be turned over to them.
• Stick to the facts. Do NOT speculate about who or what might have caused the event. Simply state what happened in clear and concise terms. For example, write “Patient who usually uses a walker slipped and fell going to the bathroom. Patient was not using their walker at the time of the fall.” Do NOT write, “Patient slipped and fell going to the bathroom. They should have been using their walker.”
• Present the facts in chronological order. Make notes of exact times and what happened. Start at the time you arrive on the scene or discover the event. Example: “0920: Entered patient’s room to administer medication. 0921: Verified patient’s identity. 0922: Discovered medication was not the same dose as prescribed. Did not administer. 0924: Notified pharmacy of the discrepancy.”
• Include photos and videos. If your organization allows, taking photos, audio, and/or videos can provide valuable supplemental information. Technology makes it possible to document events in real time, with greater accuracy, allowing for proper investigation and resolution of unplanned incidents.
• Avoid judgment. Never include your opinion about how the incident occurred. Do NOT blame the physician who wrote the wrong order, the nursing assistant to didn’t raise the bedrail, or the housekeeper who left their cart in the middle of the hall. These can have serious implications for those mentioned in the document, as well as yourself.
• Use quotation marks for anything that the patient or a witness states. Quotation marks indicate details from another person’s perspective, in their exact words. Do NOT document “Patient stated they were wrong to get out of bed without help.” Instead, write, “Patient stated, ‘I was wrong to get out of bed without help.'” The difference is enormous, because it goes from subjective to objective.
• Include your own actions. Don’t forget to document the actions you took. Did you provide emergency care? Call the Rapid Response Team? Notify the family? Clean up the mess? Label defective equipment and place it out of the way? Show how you responded in a professional and thorough manner.

They are part of nursing, too

You probably didn’t learn much about incident reports in nursing school. They are a normal part of a nursing career and are not likely to go away. When filed promptly and completely, they are the best way to protect yourself from malpractice and other legal action.

When you accurately document an unplanned situation, you should have nothing to worry about. No matter how trivial the event seems, filing incident reports is part of every nurse’s job description.

About the Author

Winona Suzanne Ball

Nursing Adviser, RN | MHS, Governors State University, IL Full member of the American Nurses Association. Learn more

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How to Write an Incident Report - With Examples

According to research on safety management among nurses (in hospital settings), "Despite 94.8% of registered nurses being aware of incident reporting systems, only 32% reported an incident in a month, indicating a critical gap between awareness and practical reporting practices in healthcare institutions."

It can drive severe consequences for overall safety in a workspace and shows that mastering the art of incident reporting is fundamentally integral to the effectiveness of your workplace safety and risk mitigation.

In this guide, you’ll learn the keys to:

• Optimizing the incident reporting process
• Crafting a detailed incident report
• Understanding the core elements of effective reporting
• Writing a compelling and structured narrative
• Adapting examples of incident reports for clarity
• How to find incident report forms tailored to your sector
• How the newest incident reporting software can change your approach

Equip yourself with the knowledge and the tools to transform your incident reporting from tedious form completion to a smart working environment. From basic principles to safety incident management software , your incident reporting toolkit is right here.

Incident Report And Its Purpose

An incident report is a formal written document that serves as a reference when an unexpected event or accident occurs. This event could result in injury, damage to property, or work interruptions. 

The main purposes of an incident report are to:

• Capture key details of what happened while events are still fresh in witnesses’ minds. It is the document of who, what, when, where, injuries/damage sustained, equipment/property affected, actions taken, and more.
• Allow a thorough investigation of the root causes and contributing factors that culminated in the incident. The more thorough your report, the more insight it provides on how and why the incident transpired.
• Identify any safety or operational policies violated that were part of the incident. It reveals if any protocols were not followed or were overlooked altogether.
• Inform subsequent action to prevent any similar incidents from occurring in the future. It will help management to see where they need to make improvements in processes, training equipment, policies, facilities, etc.

[ YOU CAN ALSO DOWNLOAD THIS FREE GUIDE TO EFFECTIVE WORKPLACE INCIDENT REPORTING ]

Core Components of an Effective Incident Report

Fundamental information.

The fundamental information outlined in an incident report includes:

• Type: Categorizing the incident provides a point of reference. Common types include injuries, property damage, security incidents, workplace violence, environmental problems, privacy breaches, and more.
• Location, date and time: The “where and when” of any incident is a must. Be as specific as you can with location, and with date and time.
• Names of individuals involved: List all people involved in the incident. Give the full name and any title or role, i.e., Robert Patterson, Security Guard. If there were injuries, list the person who was injured and list witnesses with their titles or roles, i.e. Alice Lansing, Accountant.
• Injuries sustained: Include a list of injuries, first aid that might have been administered, and any medical treatment. No injuries? State, "No injuries were sustained."

Specific Details

The specifics of an incident report provide important context:

• Equipment involved: Make a note of any tools, machinery, materials, chemicals or other equipment involved in the incident. Include the manufacturer, model number if it applies, and precise details of how the equipment was being used.
• Events leading up to the incident: The reconstruction of events can offer a number of insights into causes. Provide a concise chronological sequence of events leading up to the incident.
• Account of the incident: A detailed, chronological narrative of the incident itself will bring the incident to life. Use precise, objective language, quoting any witness statements where relevant.
• Subsequent events: Make a note of any actions that were taken after the incident, such as first aid, medical treatment, notification of the appropriate authorities, or checks for any damage or maintenance required on the equipment involved.

This leads to a basic account combined with vivid detail, making a full and useful incident report. The combination allows for the causes to be properly investigated and for the incident to be the basis for preventing similar eventualities.

Crafting an Effective Incident Report

A narrative structure is essential while writing an incident report. Organize the report into three basic sections:

Introduction

Who, what, where, and when should be answered in the introduction. As an example:

“Jane Doe, an ABC Company cashier, was involved in an incident around 10:15 am on Tuesday, March 1, 2022. The incident occurred in the company's headquarters breakroom at 123 Main St, Anytown, USA."

From here, we know that Jane Doe was involved, an event occurred, on Tuesday, March 1st, 2022, at 10:15 am, and in the breakroom at 123 Main St. It shows how this introduction sets the background for the report.

The body details the incident from beginning to end. It includes all relevant occurrences before, during, and after the incident.

As an example:

“Jane Doe walked into the breakroom and made her coffee at the coffee maker. As she reached for the coffee pot, she slipped on a puddle liquid and fell to the ground. The coffee pot struck her right calf and shattered. Jane Doe screamed out in pain with the fall.”

The body reaffirms who, what, where, and when, as well as the chronology.

The conclusion describes the resolution of the incident as well as key findings. As an example:

“Emergency services were called at 10:18 am. Jane Doe was removed by ambulance to Riverdale Hospital for a laceration of her right leg. She received 12 stitches. The broken coffee pot was cleaned and thrown away. Facilities were made aware and requested to keep a supply of Wet Floor signs positioned near breakroom spills.”

In the conclusion, the resolution and incident investigation recommendations are briefly stated to bring the matter to a close.

This introduction-body-conclusion structure makes incident reports logical and complete and makes them easy to understand. A story that winds its way to a conclusion makes a whole lot more sense.

Incident Report Example – How To Write It?

Here’s how an incident report will be written for “Main Office Security Incident - Unauthorized Entry Attempt”:

(This Incident report is vital, because it captures the security event and can be reviewed to make future security improvements.)

Other Examples Of Incident Reports [Manufacturing And Mining Industry]

Manufacturing Industry Incident Report Example:

Mining Industry Incident Report Example:

Incident Report Forms (For Different Organizations)

Reporting incident forms are the usual medium used to document incidents. They are tailored to the sector and the organization, so incident report forms differ. Here are a few examples:

General Staff Incident Report

These generic staff or personnel incident reports are employed by many businesses to log employee, customer, and visitor incidents. A general staff incident report generally includes:

• Person’s name and contact details
• Incident Time, date, and site
• Pertinent details about what happened
• Kind of injury or damage
• Name of witnesses
• Safety measures taken Suggestions for prevention

Here’s what a normal general staff incident report looks like:

Incident Report Construction Site

Construction job site safety guarantees in-depth incident reporting. Construction incident reports include particulars, for example:

• Name and role of person injured or involved
• Date, time, exact location, and description of incident
• Type of injury or illness sustained
• Equipment, materials, or chemicals involved
• Actions taken following the incident
• Suggestions to improve safety and prevent recurrences

A normally used construction site incident form looks like this:

Hospital/clinic Incident Report

Healthcare utilizes unique incident report forms to describe patient care, medical therapy, pharmaceutical errors, laboratory mishaps, confidentiality breaches, and a whole lot more. A healthcare facility or hospital might have an incident report that includes:

• Patient safety incidents, falls, infections, or privacy breaches
• Medication errors or equipment malfunctions
• Workplace injuries to staff
• Security issues, theft, property damage, or vandalism

Here’s a sample of patient incident report form usually used in clinical settings:

Incident Reporting Software For Smarter Workplace Management - SafetyIQ

SafetyIQ is an advanced incident reporting software that transforms incident reporting by providing a sleek, user-friendly platform that sets new industry standards for workplace safety.

Emerging as the leading incident reporting solution, SafetyIQ is redefining workplace safety with a variety of next-generation features and comprehensive free guides.

Take a closer look at the key features of this tool:

• Effortless Incident Reporting: The platform simplifies and centralizes the incident reporting process, allowing users to submit full-featured incident reports – complete with multimedia documentation – with minimal effort.
• Customization for Unique Needs: SafetyIQ tailors incident report forms to meet the unique requirements of each organization, expediting incident data capture and analysis in the process.
• Proactive Safety Measures: This platform is a host of specialized solutions for managing high-risk scenarios – Journey Management , Lone Worker Management , Fatigue Management , and beyond. It helps steer organizations beyond compliance and toward a proactive culture of safety.
• Real-time Insights and Analysis: Organizations enjoy a comprehensive suite of reporting dashboards that reveal the hidden safety performance insights within their data in real-time, featuring color-coded charts and infographics that allow for rapid identification of movements.
• User-Centric Design: The entire solution is designed with an emphasis on the end user, prioritizing a clean, user-friendly interface for both field workers submitting incidents and the managers analyzing the safety trends within their organization.

This software turns incident reporting into the beginning of a proactive safety culture by equipping organizations with the resources they need to put in place world-class safety practices continually. With its ability to assign corrective actions based on a data-driven approach, SafetyIQ is the best solution for workplace management and safety.

FAQs - Get More Answers Here!

Incident reporting software is a tool designed to streamline the documentation of untoward events or accidents in a business or workplace, which is crucial for reference, investigation, and informing corrective actions. It ensures a systematic approach to safety incident management.

SafetyIQ allows live incident reporting through its user-friendly platform, enabling real-time submission of multimedia-rich incident reports for immediate documentation and analysis of safety incidents.

SafetyIQ offers incident report templates that capture the critical information followed through a structured format, enabling consistency and completeness in incident documentation.

SafetyIQ has a user-centric design from the bottom up for an intuitive user experience that makes it easy for field workers to submit live incident reports and managers to analyze safety trends and overall enhance the incident reporting and management process.

Live incident reporting is simple and easy with the online platform. It enables the convenient and immediate submission of data-rich incident reports in real-time. Companies can customize the tool features to support unique requirements and enable proactive safety measures.

We cover a range of topics in our articles - view all blogs .

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Things You Need To Know About The Incident Report In Nursing For 2024

Posted 27.01.21 by: Bond Seidel

Updated June 3, 2024.

Understanding when and why you need to approach a situation as an incident is sometimes confusing for those minor situations that may seem like they are not worth mentioning. But what exactly constitutes a situation or event where you must file an incident report in the nursing field? 

A minor event may not be significant enough for you to stop what you’re doing and fill out an incident report in a busy ward. That is until it becomes a liability for you and your facility. Here’s the first thing you need to know about the incident report in nursing:

Table of Contents

1. What Is An Incident Report In Nursing?

An incident report in nursing is a report which details an event where a person is injured, or property is damaged. If these conditions occur on medical facility property, completion of an incident report is necessary.

Now that we’ve defined the first of four things you need to know about incident reports in nursing, let’s look at the others. 

Some healthcare facilities have standards that are different from others, so we’ll define a baseline standard, and you can use this relative to your facility’s reporting standard. Even if the standards are different, the concept will remain the same. So, join us in examining the incident report in the nursing field and four things you need to know.

2. When To Report an Incident Report

There are going to be times when reporting an incident is a no-brainer. For example, a patient slips and fractures their arm. That’s a severe injury from a simple slip, but it happens more times than you might think. What if a patient stubs their toe on an IV cart wheel while going to the restroom?

Many situations seem trivial and not worth reporting. In some cases, nurses fear reprisals for having an incident in their ward. So, sometimes, they fear reporting any incident, albeit trivial ones, even though it is in their best interest to do so.

How do you define a severe incident worthy of reporting from a minor one? Each facility will likely have its version of these definitions. Indeed, no hospital practices medicine without a team of lawyers deciding what is or isn’t worthy of note-taking. But, in case your facility’s policies seem a little lax in the explanation department, let’s see if we can lend a hand to your dilemma.

Regarding liability, we’re not lawyers, and you should always seek legal advice. However, we know a thing or two about incident reporting. And it seems fitting that an event becomes a reportable incident when it meets one or both prerequisites:

• A person sustains an injury.
• Property sustains damage.

Want to know how your incident reporting program could send instant notifications when an injury or property damage incident report is completed? Try the 1 ST Reporting app and discover what digital reporting can do for your facility.

When A Person Is Injured – File An Incident Report

When devoid of a clear and concise plan, the simplest way is to report any injury. It could be as minor as a paper cut in this case. There is no grey area defined, so it’s simple to understand. Any injury requires a report. 

With this definite ruling in practice, a medical facility has the best chance of catching and correcting potential hazards. The potential for an improved standard of care for patients becomes evident when there is no grey area in an incident reporting program.

When Property Is Damaged File An Incident Report

Similar to an incident report in nursing for injuries, you can include a polarized property damage reporting policy in your reporting practices. That is to say, incident reporting happens if damage occurs. The approach is black and white, with no grey area for misinterpretation.

With a reporting strategy of zero tolerance, nothing escapes reporting; minor damages are all reportable. It could be as simple as an IV or med cart’s wheel breaking or a broken mirror due to a patient’s outburst. No matter the cause, if the property is damaged, it should fall into the required reporting category.

3. What To Report

We’ve discussed when to report without a clear and concise reporting procedure for your medical facility. However, determining what to write is a slightly different topic. Why? We must clarify what constitutes injury or damage to a person or property. It’s this definition that may have a grey area of its own that can, in some situations, cast doubt upon whether or not to file a report.

Nurses know that sometimes you’re busy – extremely busy! There are near-miss incidents every minute in a busy ward, just stand and watch a swinging entrance door, and you’ll see multiple safety close-calls. But it doesn’t stop with doors; there are safety concerns around every corner in medical facilities.

And how should one define an injury? A minor paper cut may heal in a day or two, so does it count? If a ward is bustling and the nurses are busy, there is a likely chance that nurses may avoid an incident report for minor concerns like paper cuts or stubbed toes.

But what happens when a patient returns with a lawyer six months later and demands restitution for alleged mistreatment for some minor paper cut or toe-stubbing incident? If there is no record, you may stand little chance of defense.

The lesson to this dilemma is always to file an incident report if you are notified of an injury, no matter the severity. It’s the only way to ensure that you’ve got a record to fall back on later to protect yourself and your work facility.

Learn 12 things to include in an incident report (with five tips on writing the report better).

4. Why Nurses Need To File An Incident Report

There are five primary reasons why nurses need to complete incident reports: 

Personal Liability

Facility/organization liability, enhanced patient care and facilities.

• Improved Workplace Safety Culture

Improved Restitution Process

Morally, we’re supposed to ignore personal liability and ‘just do what’s right.’ However, in a world where people throw lawsuits like we throw candy to children on Halloween, you’ve got to cover your bases.

No one wants to think they will be named in a lawsuit, but it happens daily. So, merely for personal liability, nurses should complete incident reports with every event that includes property damage (or loss) or injury to anyone.

It doesn’t look right to get fired. No one wants to lose one’s job. Worse yet is to get blackballed in your area due to a facility administration getting sued over something you neglected to report. It is not an issue of personal liability (but, in a way, it could be).

Keeping your facility out of hot water by maintaining a strict incident reporting regiment is a wise practice. 

Documenting incidents of every type is the only way that safety and operations managers can implement new, evolved, or replacement procedures. From a simple material change to a procedural makeover, a facility cannot improve its functions without documentation of how an incident came to pass. And we all want a better working environment that strives to improve. In medical facilities, a minor improvement could make the difference between life and death for a patient.

Improved Workplace Safety Cultur e

In any organization, whether a medical facility like a hospital, a clinic, or another medical establishment, one thing is right. When everyone follows the rules, it’s easy to follow them yourself.

It is valid for incident reporting in the nursing community as well. No one becomes the oddball out when everyone joins the team effort to improve safety.

Hospitals are, unfortunately, places that see a lot of incidents. People from every walk of life find their way to hospitals for one reason or another. Sometimes, incidents occur, such as a person’s belongings being stolen. If someone tells a busy nurse of the infraction, but the nurse does not file a report, how will administrative staff know what restitution is deemed fitting given all the facts?

Documenting all incidents within a medical facility is critical for nurses to aid in maintaining safe and fair facilities. The goal should be for facilities where patients, visitors, and staff alike are treated with dignity and respect. That means they have the right to make claims and find reward in restitution if the situation warrants it.

The Final Thought On Incident Reporting For Nurses

The best advice is always to complete an incident report when an injury or damage occurs. A good facility management team will embrace an open reporting policy and discourage retribution to any nurse who does their duty by completing an incident report.

In any case, the only way to truly protect yourself is to complete a report and complete it factually and without judgment or bias. Completing factually and indiscriminately ensures that you genuinely cover your bases and don’t just create further headaches to deal with in the future.

Learn more about why you should complete incident reports.

Frequently Asked Questions

How do you write an incident report in nursing.

Writing an incident report in nursing is similar to writing an incident report in other industries. Following a procedure of steps when writing an incident report ensures uniformity of reporting processes and conformance with facility regulations. Learn more here about how to write a complete incident report in only 11 steps.

What are examples of an incident (in nursing)?

Incidents in nursing can range from a wide variety of events and situations. Some examples of incidents in the nursing world are: – accidental needlesticks – trips, slips, and falls – medication errors

What makes a good incident report?

A good incident report is a report that includes the vital pieces of information needed to document the incident. There are four things the writer can do to ensure the document is superior: 1. Write factually and impartially. 2. Never place judgment, blame, or make assumptions in the report. 3. Only report facts, not feelings or impressions. 4. Record data to the best of your ability quickly and efficiently while maintaining descriptive information gathering.

What is the purpose of an incident report?

The purpose of an incident report is to document any event that could affect the safety, health, or well-being of patients, staff, or visitors. These reports provide a clear and detailed account of incidents, helping healthcare facilities identify and address potential risks. Incident reports serve as valuable tools for improving patient care, enhancing safety protocols, and ensuring compliance with regulatory standards. They also protect healthcare providers by providing a factual record of events, which can be crucial in legal or administrative proceedings.

How to write an incident report for a nurse?

Writing an incident report for a nurse involves several key steps: 1. Immediate Documentation: Write the report as soon as possible after the incident to ensure accuracy. 2. Objective Description: Describe the incident objectively, including the date, time, and location. Avoid subjective language or assumptions. 3. Details of the Incident: Include a detailed account of what happened, who was involved, and any witnesses. Mention any actions taken immediately after the incident. 4. Patient Information: Provide relevant patient details, such as name and medical record number, while maintaining confidentiality. 5. Outcome and Follow-up: Document the outcome of the incident and any follow-up actions or interventions taken to address the situation. 6. Sign and Submit: Ensure the report is signed and submitted according to your facility’s protocols.

Which situations require an incident report?

In nursing, several situations necessitate an incident report, including: 1. Patient Falls: Any fall, regardless of whether it results in injury, should be reported. 2. Medication Errors: Mistakes in prescribing, dispensing, or administering medication. 3. Needlestick Injuries: Any injury involving needles or other sharp objects. 4. Patient Elopement: When a patient leaves the healthcare facility without authorization. 5. Equipment Failures: Malfunctions or failures of medical equipment that could impact patient care. 6. Violence or Abuse: Incidents involving physical or verbal abuse towards patients or staff. 7. Infections: Any incident involving the spread or potential spread of infection within the facility. These reports are crucial for maintaining a safe and effective healthcare environment, ensuring that all incidents are properly addressed and mitigated.

Now, get out there and keep making a difference in improving your safety and those around you. Good reporting and safety come to those who make it happen.

Sources and Resources

• Wikipedia Contributors. 2023. “Incident Report.” Wikipedia. Wikimedia Foundation. May 17, 2023. https://en.wikipedia.org/wiki/Incident_report .
• ‌Besmer, Michelle, Toby Bressler, and Catherine Barrell. 2010. “Using Incident Reports as a Teaching Tool.”  Nursing Management  41 (7): 16–18. https://doi.org/10.1097/01.numa.0000384141.97069.1c .
• ‌Iedema, Rick, Arthas Flabouris, Susan Grant, and Christine Jorm. 2006. “Narrativizing Errors of Care: Critical Incident Reporting in Clinical Practice.”  Social Science & Medicine  62 (1): 134–44. https://doi.org/10.1016/j.socscimed.2005.05.013 .
• ‌P. Kantelhardt, M. Müller, A Giese, V Rohde, and S R Kantelhardt. 2009. “Implementation of a Critical Incident Reporting System in a Neurosurgical Department.” Central European Neurosurgery 72 (01): 15–21. https://doi.org/10.1055/s-0029-1243199 .
• ‌Okuyama, Ayako, Minako Sasaki, and Katsuya Kanda. 2010. “The Relationship between Incident Reporting by Nurses and Safety Management in Hospitals.” Quality Management in Health Care 19 (2): 164–72. https://doi.org/10.1097/qmh.0b013e3181dafe88 .

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The importance of incident reporting in nursing

Table of contents

What is the purpose of an incident report in nursing?

The purpose of an incident report in nursing is multifaceted and crucial for both patient safety and quality improvement as well as legal documentation. In this article we’ll tell you all about incident reporting in nursing. About the importance, who’s responsibility it is to fill out a form and when incidents should be reported. We’ll conclude the article with an example.

Why is reporting important for nurses?

Overall, incident management plays a vital role in promoting patient safety , quality of care, and professional accountability within nursing and healthcare settings. Here are some key reasons for its importance:

• Quality Improvement : Incident reports help healthcare organizations identify patterns or trends in patient safety issues. Analyzing these reports allows for the implementation of corrective actions, process improvements, and training initiatives to prevent similar incidents from happening in the future.
• Risk Management : By documenting incidents, nursing organizations can assess risks and develop strategies to reduce them.
• Documentation : Incident reports provide a formal record of any incident, error, or near-miss that occurs during patient care. This documentation is vital for legal purposes, risk management, and compliance with regulatory requirements.
• Legal Protection : In the event of litigation or complaints, incident reports serve as legal documentation of the actions taken by nursing professionals. They provide a clear account of the incident, the steps taken to address it, and any follow-up actions, which can help protect both the healthcare provider and the organization legally.
• Learning and Education : Incident reports contribute to a culture of learning and continuous improvement within healthcare organizations. By encouraging staff to report incidents without fear of blame or retribution, organizations can foster an environment where lessons are learned from mistakes and shared across the team.

Who should be writing an incident report in nursing?

In nursing, incident reports are typically written by the healthcare professionals directly involved in or witnessing the incident. This may include nurses, physicians, nursing assistants, or any other staff members who were present during the incident.

The person responsible for writing the incident report should be someone who can provide accurate and detailed and factual information about what happened. Additionally, they should document any actions taken following the incident, such as interventions, notifications, or changes in patient care plans.

When should incidents be reported in nursing?

The specific timing for reporting incidents may vary depending on the policies and procedures of the nursing facility, but generally, incidents should be reported immediately or as soon as the nurse or healthcare professional becomes aware of them. This ensures that relevant information is documented while it is still fresh in the minds of those involved and allows for timely investigation and follow-up.

By reporting incidents promptly, healthcare providers can work together to address any issues, implement corrective actions, and prevent similar incidents from occurring in the future, ultimately ensuring the safety and well-being of patients.

List of reportable incidents in nursing homes

Identifying what qualifies as an incident can sometimes be challenging. Some examples of incidents in nursing homes that should be reported promptly include:

• Resident falls resulting in injury, or without injury but with a change in condition
• Medication errors, including wrong medication, wrong dosage, or missed doses
• Adverse reactions to medications or treatments
• Resident abuse or neglect, including physical, verbal, emotional, or financial abuse
• Resident wandering off unsupervised
• Any significant change in a resident's condition, including sudden decline in health status
• Unexplained injuries or bruises

Nursing incident report guidelines

Incident reports include factual details such as the date, time, and location of the incident. In addition a description of what happened should be added as well as any actions taken in response to the incident, and follow-up measures to address the issue. The primary purposes of incident reports in nursing facilities are:

• Documentation : Providing a comprehensive record of incident occurrences, ensuring all relevant information is reported accurately.
• Analysis : Enabling investigation and examination of incidents to uncover root causes, contributing factors, and ways for improvement.
• Prevention : To help develop and implement preventive actions and measures aimed at reducing the risk of similar incidents in the future.
• Communication : To communicate important information about incidents to relevant stakeholders, including hospital administrators, healthcare providers, and regulatory agencies.

Example of a nursing incident report

Incident Report

Date : March 12, 2024 Time : 10:30 AM Location : Willow Grove Nursing Home, Room 214 Reporter : Jane Doe, RN

Incident Details : At approximately 10:15 AM, while conducting morning rounds, I entered Room 214 to check on Mr. John Smith, a 78-year-old resident. Upon entering the room, I noticed that Mr. Smith was lying on the floor next to his bed, holding his left arm and grimacing in pain.

Witnesses : None present at the time of the incident.

Description of Incident: Upon closer inspection, it was evident that Mr. Smith had sustained a fall. He complained of pain in his left arm and was unable to move it without discomfort. Vital signs were stable, with no signs of head trauma or significant injuries observed.

Actions Taken:

• Immediately assisted Mr. Smith back onto his bed using a transfer lift to ensure safety and minimize further injury.
• Conducted a thorough assessment of Mr. Smith's injuries, focusing on his left arm. Observed swelling and tenderness around the elbow joint.
• Administered pain relief medication (acetaminophen 500 mg) as ordered by the physician to alleviate discomfort.
• Notified the attending physician, Dr. Emily Johnson, of the incident and Mr. Smith's condition.
• Completed documentation in the resident's medical chart, including details of the fall, assessment findings, interventions, and physician notification.
• Implemented fall prevention measures, including adjusting the bed height and ensuring the call bell was within Mr. Smith's reach.
• Informed the charge nurse and nursing supervisor of the incident for further review and follow-up.

Follow-up Actions:

• Scheduled an X-ray of Mr. Smith's left arm to rule out any fractures or underlying injuries.
• Notified Mr. Smith's family members of the incident and his current condition.
• Implemented additional monitoring of Mr. Smith's mobility and safety precautions to prevent future falls.
• Conducted a review of Mr. Smith's care plan to identify any necessary adjustments or interventions to minimize fall risk.

Signature of Reporter : [Jane Doe, RN] Date and Time of Report Completion : March 12, 2024, 11:00 AM

Incident reporting software

By implementing reporting software , nursing organizations are better equipped to document and analyze incidents. Software tools make it possible to collect data on a larger scale which helps to identify trends. Gaining insights in these trends makes it easier to start making positive changes that benefit patient safety and quality improvements. That is the exact purpose of incident reporting.

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How To Write an Incident Report

In healthcare, safety and quality of care are paramount. Medical incident reports are tools that contribute to improving both patient care and workplace safety by shedding light on accidents and near misses, training gaps, and areas where practices may require adjustments. But to get the most out of these reports, healthcare professionals need to know how to write an incident report. 

Well-written, comprehensive incident reports are critical, and an online incident reporting system can help streamline the process.

What Is an Incident Report in Healthcare?

An incident report is a document that outlines and details any unexpected or adverse events that occur within a healthcare facility. Incident reports are an important part of maintaining healthcare standards and regulatory compliance. Proper completion and storage of reports are crucial for audits and regulatory adherence, and records must be maintained for five years.

Beyond being a tool for internal assessment, these reports are mandated by organizations like the Occupational Safety and Health Administration (OSHA) to promptly report incidents causing death, serious injury, or hospitalization .

Steps To Write an Incident Report

Incident reports are, by nature, extremely detailed documents. Because their purpose is to not only record an incident but to help prevent future similar problems, they need to be well-written and descriptive. As a result, knowing how to write an incident report requires a systematic, comprehensive approach:

• Include basic information. Begin with the date of the report, the date and time of the incident, your name, job title, and contact information. Specify the location of the incident and indicate whether similar incidents have occurred before at the workplace.
• Describe what happened. Provide a clear, chronological account of the events leading up to the incident. Be specific and precise. For instance, if reporting a medication error, include details such as the brand name, manufacturer, and the exact nature of the error. Include the names, contact details, and identifying information of individuals involved.

•  Include documentation. Attach relevant evidence or documentation related to the incident. This could involve transcripts of conversations, audio recordings, or any other information that provides context and clarity.
• Explain corrective actions. Detail the actions taken in response to the incident. Specify who was involved and the timing of these actions. This may involve stabilizing patients, notifying supervisors, revising protocols, conducting training, or initiating a root cause analysis.
• Escalate the incident report. In most cases, incident reports require review by relevant personnel. Online incident reporting systems simplify this process, automating the escalation of reports to the appropriate individuals or departments.

Why Use an Online Incident Reporting System?

Healthcare is fast-paced and every mome nt counts where patient safety is concerned. Having an efficient incident reporting system is more than just a convenience — it’s a necessity. Traditional paper-based incident reporting methods have given way to online incident reporting systems, revolutionizing the way healthcare organizations handle incidents, near misses, and safety concerns.

Here’s why healthcare facilities are increasingly turning to online incident reporting systems to bolster safety, streamline processes, and enhance overall efficiency:

• Speed and accessibility. Online incident reporting systems offer a level of speed and accessibility that paper-based systems simply can’t match. With just a few clicks, healthcare professionals can submit incident reports from any location. This speed is crucial when it comes to reporting critical incidents promptly and ensuring that necessary actions are taken to prevent recurrence.
• Real-time escalation. Incident reporting often involves multiple layers of review and escalation. Online systems automate this process, ensuring that reports are promptly escalated to the appropriate individuals or departments. This eliminates delays caused by manual handovers and minimizes the chances of incidents slipping through the cracks.
• Customizable forms for precise data collection. Every incident is unique, and gathering specific data is essential for effective analysis and improvement. Online incident reporting systems allow organizations to create customizable incident reporting forms that capture the exact information needed for each incident type. This tailored approach enhances the accuracy of the collected data and empowers organizations to identify trends or patterns.
• Enhanced documentation and evidence attachment. In the digital landscape, attaching relevant evidence and documentation to medical incident reports becomes seamless. Conversations, images, audio recordings and other supporting materials can be attached directly to the report, to provide a comprehensive context that aids in understanding the incident — and formulating appropriate responses.
• Anonymity encourages transparency. Online systems often enable healthcare professionals to submit incident reports anonymously. This feature promotes a culture of transparency and encourages employees to report concerns without fear of repercussions. Anonymity fosters a safe environment for open communication about incidents and safety hazards, leading to better incident detection and resolution.
• Improved data analysis and trend identification. Data collected through incident reports is a goldmine of information that can drive improvements in patient safety and operational efficiency. Online incident reporting systems allow for systematic data analysis , and enable healthcare organizations to identify trends, patterns, and areas that require targeted interventions. 
• Enhanced visibility for leadership. Leadership teams can benefit immensely from online incident reporting systems. These systems offer visual dashboards that present incident data in real time. This visibility empowers leaders to make informed decisions, allocate resources strategically, and monitor the effectiveness of interventions.
• Regulatory compliance is made easier. Healthcare organizations are subject to numerous regulatory requirements and reporting obligations. Online incident reporting systems streamline the process of compiling and submitting incident data to regulatory bodies. This ensures that compliance is met efficiently, to reduce administrative burdens and potential penalties.

Use MedTrainer for Your Medical Incident Reports

The value of safety, efficiency and continuous improvement can’t be overstated. Online incident reporting systems embody these principles, revolutionizing incident management, analysis, and prevention. By embracing technology, healthcare organizations can keep patients safe, support their staff, and elevate the overall quality of care. 

With the right incident reporting system — like MedTrainer — your practice can create a culture of transparency, data-driven decision-making, and swift intervention. Learn more about MedTrainer’s incident reporting system today.

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Incident reports: A safety tool

Nurses tend to cringe when they think about completing an incident report. Reasons for this reaction include the distress that occurs when something untoward has happened, anticipated loss of precious time to complete the report (particularly if the organization’s reporting system is cumbersome), and fear of being blamed for the incident or becoming embroiled in a court case. In this situation, it’s easy to forget that incident reports are a valuable resource for keeping patients safe. They also can keep employees safe by identifying system-wide problems such as insufficient staffing or equipment to move patients, which often contributes to staff injuries.

So that patients and employees can benefit from an incident report, nurses need to understand their use. They also need to know how to complete and file a report correctly to protect themselves and their organization from the report being used as part of legal action in a lawsuit brought by a patient.  

A safety tool

Incident reports provide a record of an unexpected occurrence, such as a fall or administration of a wrong medication dose, that involved a patient, a family member, or an employee. These reports can be used to identify areas of safety improvement and to educate others about how to avoid similar events in the future.   Nurses should think of the incident report as a safety tool, not a method of assigning blame. Organizations should view these reports through the lens of a culture of safety, which The Joint Commission defines as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.” One tenet of a just culture is to take a nonpunitive approach to reporting and learning from adverse events.  

When to file

Nurses should check their organization’s policy and procedure related to when to file an incident report. In general, a report should be filed when something unexpected occurs that results in harm. Sometimes nurses may be unsure whether an event warrants reporting. In this case, it’s best to go ahead and complete a report. Even if the event did not result in harm (for example, the patient did not suffer ill effects after receiving a wrong medication), it’s still important to have a record of the event so that the organization can learn from the event and the risk of a similar event can be reduced.   Typically, a licensed professional, such as a nurse or nurse practitioner, who was part of or witnessed the event completes the form. However, nonlicensed clinicians should report events and provide information as needed for the report. If the event wasn’t witnessed (e.g., the patient fell out of bed when alone in the room), generally the first licensed person who becomes aware of the event should file the report.   Reports should be completed as soon as possible after the event (and within 24 hours) and submitted to the designated person/department. Many organizations now allow employees to file reports online, with the risk management department and the appropriate manager receiving notification. Hospitals, clinics, and other healthcare organizations should make reporting as easy as possible to encourage staff participation.    Traditionally, incident reports have focused on situations where harm occurred, but many organizations now also encourage employees to file reports about “near misses” or “close calls”—events that could have resulted in harm but did not because someone became aware of the problem. An example of a near miss is the nurse who misreads a label on a medication mixed by the pharmacy department and almost administers an incorrect dose. These reports can be reviewed by risk managers and clinicians to determine changes that can be made to avoid future harm. In the case of the medication label, for instance, it might mean making the print on the label larger, so it is easier to read. The Joint Commission calls on organizations to recognize employees for reporting both adverse events and close calls, so lessons can be learned and shared.  

Incident reports and legal action

In general, incident reports, which should not be part of a patient’s health record, cannot be used in legal action. Support for this comes from the Patient Safety and Quality Improvement Act of 2005, which established a voluntary reporting system designed to encourage data sharing so that healthcare quality could be improved. The act “provides Federal privilege and confidentiality protections for patient safety information, called patient safety work product.” (To be eligible for these protections, hospitals establish a patient safety evaluation system that provides data to a patient safety organization.)   However, if the report is not completed correctly, it may end up in court. For example, in a Michigan case, the hospital was arguing that it didn’t know the cause of the injury, but a report contained an opinion about how an injury occurred (even though opinions should not be included in incident reports). The report was allowed to be included in the case, and the court issued sanctions against the hospital and its counsel for raising defenses “not well-grounded in fact.”     In addition, a few state rulings have noted that incident reports are not always exempt from use in legal action. For instance, an Illinois court ruled that a “quality-related event report” was not privileged and that a patient suing the hospital should have access to it.   Nurses can lessen the likelihood of an incident report being part of a lawsuit by correctly completing it (see sidebar). If the report ends up in court, an accurate document can help provide evidence that the nurse and organization were not at fault for what occurred.  

Completing the report

The report should include a detailed description of what happened. Most organizations have a standard form designed to capture key information such as date, time, and location of the event; name of the person who was affected; names of witnesses to the event; names of those who were notified (e.g., the patient’s physician); the condition of the person affected (e.g., any visible breaks in the skin after a fall); and actions taken in response (e.g., radiograph obtained, malfunctioning equipment sent to biomedical engineering).   Objectivity is key. Any relevant statements made by the person affected by the event or witnesses should be recorded verbatim. It’s also important to note who assessed the patient and the results of that assessment.    Although the incident report is not part of the patient’s health record, nurses should still objectively document the event, including what happened, assessment results, interventions, and follow-up (such as physician notification), in the record.  

A helpful tool

Incident reports are often seen as something to be avoided. However, if completed properly, they can provide useful information that can help keep patients and staff safe.  

    Article by: Cynthia Saver, MS, RN, is president of CLS Development, Inc., in Columbia, Md.     REFERENCES Albert Henry T. Court should respect privilege tied to quality-related event report. AMA. December 29, 2021. https://www.ama-assn.org/delivering-care/patient-support-advocacy/court-should-respect-privilege-tied-quality-related-event Engel EVM. Discoverability of workplace incident reports. American Bar Association. June 9, 2020. https://www.americanbar.org/groups/litigation/committees/products-liability/practice/2020/discoverability-of-workplace-incident-reports/ HHS. Patient Safety and Quality Improvement Act of 2005 statute and rule. HHS.gov. 2017. https://www.hhs.gov/hipaa/for-professionals/patient-safety/statute-and-rule/index.html Kelly C, Gross S. Do hospitals have an adequate patient safety system> MedCity News. March 30, 2020. https://medcitynews.com/2020/03/do-hospitals-have-an-adequate-patient-safety-system/ Kelly C, Gross S. Pennsylvania court interprets scope of Patient Safety Act privileges protections. MedCity News. August 7, 2020. https://medcitynews.com/2020/08/pennsylvania-court-interprets-scope-of-patient-safety-act-privilege-protections/ Schub T, Woten M. Incident report: writing. Nursing practice & skill. Cinahl Information Systems. 2015. The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert. Revised June 18, 2021. Waranch L. What?! Incident reports can be discoverable? Waranch + Brown. January 25, 2017. https://waranch-brown.com/wait-incident-reports-can-discoverable/         Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.   This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500 . www.nso.com .

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Nurse Incident Report

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Here is something you may not always hear everyday, the fact that nurses do a lot of reports. The fact that the reports they do are also necessary. Here’s why and why you don’t picture this situation. What do you get if you mix a nurse, an accident and a set of students? Of course you would get a good incident report to write about. But in all seriousness, this is what you would be expecting when you get into this kind of situation. There are a lot of things that could happen on a daily basis. Nurses are no stranger to these kinds of incidents. Whether it would be in the hospital, in school, or in any other places that incidents are prone to happen. Even school nurses who work in schools as part of the staff know that with students or with anyone in the faculty, any incident can happen. However, regardless of where the incident may take place, the best thing you have to also know is how you should write a nurse incident report. With that being said, here are your examples. 

4+ Nurse Incident Report Examples

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What Is a Nurse Incident Report?

A nurse incident report is a kind of report that nurses make in order to file what happened. In order to explain, write down or to inform someone as to what had happened during this time, this hour or this day. This incident report caters to the explanation of an incident that happened and the nurse who has been on duty when it happened. Basically, this incident report caters to the necessary details that happened and the opinions, the medical information and the notes that make up the entire nurse incident report. This is especially true for nurses who work in schools who often see a lot of incidents happening to students.

How to Write a Nurse Incident Report?

Any kind of health care worker, may it be a nurse, a doctor, a general practitioner knows that incident reports are useful. That to know what happened during that incident, the report tells it all. However, not everyone is able to know how to write a well written nursing incident report, and not everyone is able to get the opportunity to learn how. With the following steps, it would be so much easier for you to follow to get to know what a nurse incident report looks like.

1. Take the Time to Fill Out What Is Being Asked

Taking the time to read the questions or to write down what is being asked is the best way to start your report. The incident report may vary from incident report forms to simply writing what happened. Regardless of which type you are going to be using, always take the time to think it through.

2. Always Remember to Be Clear and Concise

Keep your answers as simple, clear and concise as possible. You are not the only one who is going to be reading the report. There will be others who would look forward to seeing the report and to be able to know what the best solution would be. In order for the incident not to happen twice.

3. Know the Responsibilities You Have for the Report

Getting to know your responsibilities as a nurse when you write your report is also important. The role that you play when you either witnessed the incident or if you were the one treating the patient during the incident. The responsibilities that you have to write would also matter in the report.

4. Information Is Key to the Nursing Incident Report

Your information should at least be based on the nursing incident. What happened is what you are going to be writing about. Avoid fabricating the information just to make your incident report look nice. The whole point of the nursing incident report is to explain what happened, and not what you think should happen. It would make the whole report pointless if you want to write to make it sound nicer than what it actually is.

5. Proofread Your Incident Report Just in Case

Proofread what you have just filled out. Just in case you may have missed something very important to put in your report. 

What is a nurse incident report?

A nurse incident report is a document that states the problems and the incident as to what happened during the accident. The people who have been a part of the incident and their issues are placed in the report.

How long is a nurse incident report?

The length of a nurse incident report would depend on how much evidence you can provide in the report. For those who are writing or filling out the incident report, it is always best to have a summary of it.

What can a nurse incident report mean?

The nurse incident report is basically used to report. From the word itself, to report an incident that happened for a nurse.

It goes without saying a nurse incident report is used as a tool to report what happened during the accident. Who were the people involved and what happened to make it happen? The report is stated for anyone who needs to know. In addition to that, a nurse incident report is made by nurses to give the information to someone who would need it. May it be for medical purposes or for a school knowledge purpose.

Text prompt

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Craft an incident report on a classroom equipment damage involving students during a group activity

Develop an incident report about a lost personal item of a student reported in the school library.

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• Critical incident report for nursing

Are you wondering what reflective writing is about? Do you need help deciding what sort of incident you should select? Are you clear on what a variable is? This series of videos covers how to structure and write a critical incident reflection.

Part 1: The preliminary guide

This video gives an overview of the assignment, some of the pitfalls to avoid and an outline of a sample critical incident.

As a professional, it’s always good to work reflectively, always being mindful of how you impact those around you and trying to see other people’s perspectives and situations. In your future professional life, there will be times when mistakes or disagreements occur and you may be called upon to negotiate or investigate these. If you do, you need to do this keeping emotions in control, taking a situation apart in a scientific way, and understanding what has led to the situation.


If you are in a position of authority, you may be called upon to document an incident in writing, and put in place procedures that will avoid an undesirable situation from happening again.


Before you start anything, you need to identify your incident first. Students often think that this assignment requires an incident that is disastrous or life-changing. Actually, this is not what you need to do, because for one, these things are usually too complex and emotional, and also they are often not based on misunderstandings of any type. You need to select a fairly mundane event, such as a minor conflict with a work colleague, or a harsh exchange with the cashier at the supermarket. What’s important is that you need to be critical, not choose a crisis.

Essentially, the incident that you choose needs to be about a failure to communicate, or a failure to understand each other, or perhaps a failure of the system that has led to a conflict or a difficulty between parties.


Give a minimum amount of detail of what happened, give only what’s necessary to understand the analysis or reflection that will follow. Retelling the story does not achieve a lot, it’s the analysis and reflection that matters. If you feel that you really need to give a more detailed description, put that in the appendix and just use a brief summary in the report itself.


The incident that you select needs to be very specific. Something you can identify at a particular time and a particular place. Once you’ve chosen your incident, you need to unpack the situation.Choose a true situation rather than a fabricated one, because that will make this part much easier. It will also sound more authentic in the end. You need to use a common sense, reflective approach to list everything that contributed to the situation.


For example, I’ve analysed a disagreement that I had at home last week. The blue boxes around the edge are the things that contributed to the situation. You should recognise that many of them involve the variables suggested in your assignments. Variables such as environment where the argument took place, or the different cultural values of the people involved. But remember, your situation is unique. The variables suggested may be relevant or they may not. You need to engage with the situation and really sort out what the variables are of your situation. Some of them may not even be on the list.


Once you’ve pulled your situation apart and analysed what went on, you need to link your thoughts or conclusions to the literature. Remember though, it is a reflective piece, and a reflection is based on your thoughts and feelings first. It is not based on the literature. In a way, this report is a case study, and the case is always central to the writing, be it a patient, or in this assignment, it is an incident.


An essay is based primarily on literature,. however, a case study or a reflective writing piece is not. In this report, you need to make links to the literature in saying what you want to say. But do not let the literature dominate. Let it support what you want to say, or your message will become unclear. Always keep your story and your analysis upfront and central.

Part 2: Incorporating the literature

This assignment involves reflecting on YOUR particular incident, but at the same time you need to integrate relevant information from the literature. This video will provide some guidance of how this can be done.

Let’s return to my situation from the previous video, where I was analysing a disagreement I had with my husband about our teenage daughter going away overnight. Let’s just focus on a few of the aspect variables of this case. First of all, my husband and I bring different ideas to the table about what it means to be a parent. To explore this deeply, I might refer to key terms such as these. These might draw from a wide variety of fields such as psychology and in particular, parenting, of course.


Another aspect of this case is that we’d heard. So our assumptions and perceptions play a big part in this incident. To explore this more deeply, we might talk about adolescents and peer pressure. This may draw from many fields that look at how adolescents think and behave, what detrimental behaviours they may indulging in, and what percentage are actually doing so. Another aspect that I will explore is that my husband grew up in a fairly traditional Greek immigrant family. Now, as a father, he presents many different ideas and values that he was raised in. To explore the differences that this creates, I might need to read something about Greek culture, their social values, and their concepts of honour and gender roles for women. Now, this is certainly not something that you would go looking for before you had your incident worked out.


When you go looking for references, books are a good place to start. They are easier to understand when you first get into a topic, and they will give you the general idea. Their limitations, however, are that they do not go into anything very deeply. They do not have the depth and detail that a research paper needs at university level, and the higher you go in tertiary study, the truer this becomes. Most books are on the shelf for a number of years, as well. In medicine and nursing, there is a need to limit your resources that have been published in the last five years. The reason for this is that the medical field is evolving so rapidly that most technology, techniques, and drugs are completely different even after just a few years. In medicine, five years is a long time.


In other fields however, this is a little more relaxed. In fields such as psychology, or education, ten years would be acceptable, but the more recent the reference, the better it is, of course. So when you select your references, keep the field in mind because the requirements for medical references are quite stringent, and the five-year rule might exclude some useful and appropriate references from other disciplines. Apply your common sense to this, and if unsure, don’t hesitate to ask a lecturer from the field.

The internet is another useful source. But as you know, anyone can create a webpage, so be careful. Look at the fine print at the bottom of the page, which often includes the date the web page was last modified, and make sure the website is controlled by a reputable authority or institutions. Blogs, wikis, and dot com sites which aim to sell things to you are not suitable for academic references.
The best references are peer-reviewed research journals, which you search for and can access through the databases of the library. These are reputable and contain sufficient depth and detail. However, journals – whether they are electronic or paper-based – are not good places to start your research. They usually detail very specific studies that were carried out, and their language and findings are quite specialised. They are something to tackle when one, you have some familiarity to the topic, and two, you know exactly what you’re looking for.


So, what now? Ponder your incident deeply and reflectively. Perhaps discuss it with a friend to get another person’s insights into it, and then write it out all in one go. Forget the references for the time being. This will give you the structure of your critical incident report, and this could be done in a few hours.


After that, read it over and see where your references could inform or expand on some of the things that you have touched on. Since this is largely about communication, change, and personal growth, there are any number of theorists that can give you a structure for analysing your incident. You might like to refer to their categories and analyses when thinking about what went on in your incident. I would, however, use them sparingly, because you would also have to explain their theory, even briefly, and this could chew up a lot of word space.

Part 3: Structures for reflective writing

Avoid a rambling stream of consciousness that recounts what happened when. There is a structure to the writing process as well as the reflective process. View this video to see what you need to think about and say in regard to your incident.

Reflection is a creative process and does not always follow a linear logic in the same way that essays or reports do. However, reflection is still an academic genre of writing and it’s necessary to follow a structure. First and foremost, your reflection still needs to be written in paragraph form - just like any other genre of academic writing, which always requires structured paragraphs. Secondly, the process of thinking reflectively can be structured as well; however, it depends upon the individual and the situation as to how this is done in the end.


A possible framework for a reflective process is the D.I.E.P. model. This is only advisory; however, it does touch on every aspect of thinking reflectively. At the very least it may generate some avenues to explore with your reflection. 


The ‘D’ in the ‘DIEP’ stands for describe. It is necessary that you first describe the situation you’re reflecting on. Do note, however, that this does need to be kept as brief as possible. Describe what you only need to describe so that your reader can follow the rest of your reflection. Recounting the details of your incident does not constitute reflection per se. It would be a mistake to let the description of your incident go beyond a quarter of the word space.


The next part of the structure, is the ‘I’ for interpret. This is where you state the significance of what happened, what does it mean for you, or how does it impact you. A similar situation can occur for two people, but it will affect them differently because they interpret the event differently. 


The ‘E’ stands for evaluation. In this space, you can make judgement on things. This may be on the outcomes of the situation on the people involved in the confrontation, or, most importantly, on yourself and on your own behaviour. Whatever your evaluation of a person or situation is, it needs to be balanced and supported by reasoning. Do not make judgements from a position of blame but rather towards the goal of understanding. And remember, evaluations in the real world are seldom black and white. There will be shades of grey, composites of good and bad, or successful and unsuccessful. 


The ‘P’ in DIEP is for planning, and this is the section where you can look forward towards your reflection. This is where you think about the next time, how the experience has changed you, or exactly what you need to do or want to achieve in the future.


Finally, although reflective writing is another type of academic writing. You are allowed to, unlike other forms, use the pronoun ‘I’. You would not mention yourself in an essay, or a report, however, it is valid to say ‘I feel’, or ‘I believe’ in a reflection. Because this after all, is the focus of a reflective writing. None the less, your lecturer may ask you to write to the third person. Saying, the author thinks or this writer believes. Because this makes the text sound more objective and it may give you a more analytical or detailed stance as well.


Paragraphing is a very important feature in your writing –like any other genre of academic writing. Reflection needs to be structured, logical and clear. It is not written as a stream of consciousness where each idea merges into the next. Ideas need to be identified and separated by paragraphing. And the initial sentence, known as the topic sentence, clearly states the concept to be delivered in each paragraph.

In each paragraph in a reflective writing piece, the following sentences will expand on the ideas stated in the topic sentence. They might be citing the literature relevant to the topic sentence; they might be given to reflection, exploring your feelings and beliefs in relation to the topic sentence. The final sentence is termed to a linked sentence; it can summarise and make sense all of the detail given in the paragraph so far. It brings the information back into context, with the confrontation or misunderstanding you’re writing about. I call it the ‘so-what’ line, right what you would if somebody asked you, “well… so what?”.


Although the linked sentence is not mandatory, it is a very good idea for long paragraphs. It also a very good idea in reflective writing because it makes you anchor your reflections and literature back to the real incident –which is what the assignment is all about.

Part 4: Sample paragraphs

If you are still unsure about what to do, watch how a sample incident can be analysed.

Just to recap, I am reflecting on an argument that was introduced in the previous session. I had had an argument with my husband about our teenage daughter staying out overnight. I identified several of the variables that fit into and exacerbated argument. The one I will focus on here is the notion that my husband and I approach parenting in different ways. In short, what happens in my reflection is that I identify exactly how my husband and I differ in parenting, and. I find some categories in the literature to describe these differences.


Through the literature and further reflection, I realise that parenting differently is not a huge issue and, in fact, it is almost impossible to have complete consensus in parenting styles. I realise that my need to agree with my husband on all issues dealing with my daughter, was making me frustrated, and this probably made the argument worse.


The first paragraph sets the context part of this reflection. No deep reflection is being entered into as yet. The topic sentence highlights the key point of the paragraph. Namely that my husband and I often approach parenting issues in different ways. The first reference I use is quite old, from 1971. But this particular reference is the first time the categories for parenting styles were coined. So, it is considered a classic work in the field. In the next sentence in blue, I relate the information gained in the literature to the present situation.

Remember the incident is central to the writing, so. there is no point in including literature that has little direct relevance to your incident. Always explain how the literature reveals something about the situation, and as I did in the next sentence in black font. Find some literature that describes or expands on your situation. You need to keep a continuous conversation between the literature and the details of the incident. The final sentence in this paragraph is what I call the link sentence. It sums up the point of what I’m saying in the paragraph and it should correspond to the topic sentence at the beginning of the paragraph.

In the next paragraph, once again the topic sentences are in red. This is the cracks of the issue here, then I immediately relate it to what this means in the confrontation we had; and I’ve done this in the blue. Where possible, I relate the literature to my situation as shown in the black text. I then move onto some reflection as shown in the green text section. Here, I explore why different parenting style issue was an issue in the confrontation at all. I finish with the linking sentence which makes sense of this reflection. It brings things down to earth and back to the real world and more importantly the incident that we are analysing in the first place. It also returns to the point established in the topic sentence.


In the next paragraph, the core part of the sentence is shown in red. The key point of this topic sentence is that I always felt that I had to agree on my husband about parenting. In the text in green, I start to move into some analytical reflection, where I look back at my own thinking and possibly question the things that I’d believed. Be sure to explore what you feel and believe. Question it, do not just state it. Dig down deep, and find out why you feel and believe the way that you do. In the black text section, I find some literature that talks about consensus in parenting styles but I need to immediately bring that back to what it tells me about my situation as a I do in the last line in blue. What it does tell me is that, lots of couples exhibit different parenting styles, this sentence is not a linked sentence summing up the paragraph. But it does move the reader onto the next section where I will talk further about having different parenting styles.


In the next paragraph marks a shift in my understanding of the situation. Reading the literature has caused me to reflect further and deeper; and there’s no reason why this cannot feed into the reflective process as well. My realisation is expressed in the topic sentence, shown in red. Namely whatever we do, my husband and I will always be perceived differently. And this is followed by a number of sources that expand and further this idea.


In the final paragraph I have managed to come to some resolution that will move me forward. The final stage of the reflective process can be denoted as the planning phase. This means that we might think about where to next? with the issue; or how this understanding may change our behaviour in the future. You may or may not get to this stage with your reflection of your incident. It’s not completely necessary that you do. Here, however, I have arrived at the understanding that common parenting approaches are not as important as I had previously thought. And as I reflect in green, what I really hope for is to have open communication between the three of us.


The final sentence is the link sentence – it echoes the idea started in the topic sentence by saying that the argument was made worse by my anxiety, which was mostly unnecessary. More importantly it brings the reader back to the incident or confrontation – which is what the assignment is all about. A reflection can go in many directions exploring ideas and feelings surrounding the incident, but, the paragraph will be much stronger if the reflection turns to the incident to clarify how it changes our understanding of the specific incident


So, in summary, although this is a reflective piece it should not be written as a long meandering chain of thought. It requires structure and paragraphing. Just like any other academic writing. So, use topic sentences and use linked sentences in order to bring up the ideas back to the situation. Keep that conversation going between the literature and the critical situation. Constantly relate one to the other, do not discuss literature or a theory that has no impact upon the critical incident.


And finally, reflect deeply and delve into the reasons of your feelings. Do not just identify them, and be open to the literature changing your views and understandings. At first you need to link your reflections to the literature, but this can be a cyclic process where the literature feeds back into your reflections as well. This, however, means that your writing could get quite long, so the key here is to limit the scope of your incident in the first place. Select a simple confrontation, because it is better to reflect deeply on a few variables rather than spreading your focus across a complex matter – making the reflection too broad and too shallow.

• Writing an academic reflection

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Incident reporting.

Consolato Sergi ; Donald D. Davis .

Affiliations

Last Update: July 25, 2023 .

• Definition/Introduction

Medical errors currently represent a serious public health issue, as they pose a severe threat to patient safety. The introduction of new clinical approaches, procedures, and laboratory techniques accompanied by increased bureaucracy in the life of a physician has resulted in tremendous challenges in his or her practice. Numerous studies over recent decades have shown an increased incidence of burnout syndrome and suicide rates in physicians and personnel of allied health care providers across several countries. Diagnostic errors in medicine are not infrequent, although our approach to these situations has changed notably from 40 years ago, as today there is a shift from placing blame upon an individual to identifying the cause of a medical error, as well as the application of policies to limit complications and prevent future such medical errors. 

Improving individual outcomes is a vital component of every clinician’s training and continuing professional education. To optimize outcomes and prevent medical errors, policymakers must be able to identify the root cause of each medical incidence. Understanding the underlying cause of a medical error can be challenging, as there is generally a multifactorial pathway that leads to suboptimal clinical results. However, increased incident reporting inevitably leads to improved root cause analysis and policies that cause medical errors to become rare.

• Issues of Concern

The Institute of Medicine (IOM) gave the following definition for error: "the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim." In contrast, a diagnostic error was defined as: "error or delay in diagnosis, failure to employ indicated tests or therapy, failure to act on the results of monitoring or testing." Finally, an adverse event is defined as: "an event that results in unintended harm to the patient by an act of omission or commission." [1]  To reduce the incidence of errors, tasks such as the identification of causes, setting solutions, and measuring the success of improvement efforts are divided among different members of the healthcare team.

Reporting an incident is critical in improving healthcare and is exclusively based on the principle of learning from prior medical errors. These events may not need to cause death or even harm to the patient. Incident reporting includes near misses, that is events that did not result in patient harm, despite having harmful potential. There is often difficulty in linking cause and effect when examining adverse events.

• Clinical Significance

In 1991, an analysis of 203 incidents of cardiac arrest at one teaching hospital discovered that 14% of patients experienced an iatrogenic complication. [2]  One review by Bodell et al. reported that greater than half of deaths caused by medical errors were preventable.

There are three identified types of medical errors: systemic errors, cognitive errors, and no-fault errors. System errors are defined as technical or equipment failures, or alternatively, organizational flaws. Cognitive errors include errors deriving from inadequate knowledge by medical practitioners. No-fault errors are made during the provision of health care that could not be foreseen and would be impossible to prevent even by the most careful practitioner. 

Appropriate identification of the type of error will allow regulatory boards and policymakers to develop appropriate policies that can reduce preventable medical errors, improving both the quality of patient care, and reducing the liability of medical institutions. [3] [4]

• Nursing, Allied Health, and Interprofessional Team Interventions

Reporting of medical errors is the first step to improving medical care. It relies on the development of policies that address the root cause of medical errors and the provision of clear communication and training to all members of the healthcare team. Nurses, therapists, mid-level providers, and physicians all play an essential but unique role in delivering appropriate patient care. Therefore, representation of all members of the medical team should have representation on policy boards that review medical incident reports and develop policies to prevent future such errors. Once these policies are in place, members of medical regulatory boards need to communicate new policies clearly to all members of the healthcare team. [5] [6] [7] [8]

• Nursing, Allied Health, and Interprofessional Team Monitoring

Since the 1980s, the approach to addressing and preventing medical errors has tremendously improved. Improved methods of incident reporting have led to an improved relationship between patients, physicians, and medical regulatory bodies. Furthermore, advances in electronic medical records improve our ability to develop policies to maximize patient outcomes. [9]  Continued improvement in medical care requires the use of information gleaned from incident reporting, and electronic medical records must influence training programs for medical practitioners. [10] [11] [12] [13]

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Disclosure: Consolato Sergi declares no relevant financial relationships with ineligible companies.

Disclosure: Donald Davis declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Sergi C, Davis DD. Incident Reporting. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Incident Report

Despite the most careful precaution of medical personnel, medico-legal accidents still occur. In all cases of accidents nurses caring for the client during the time of incident and those who saw or heard the unusual event should write an incident report. The nurse in charge of the department should also write an incident report in cases of accident. Sometimes, elderly patients in the care home sometimes show signs of neglect or abuse, which is when getting in touch with qualified nursing home abuse lawyers at places like the cain law office would be a step worth taking, especially if you care for the welfare of these patients.

An incident report is a form that filled up in order to record the details of accidents, patient injury and other unusual events that occur in a health care facility such as a hospital or nursing home. It is also called an accident report which documents the exact details of the accident or unusual event while the information is still fresh in the minds of those who witness the event. A remedy for your injuries is essential in order to get justice for the accident. An incident report will be essential to support your legal injury case.

Purpose of an Incident Report

People often regard an incident report as a black mark against the nursing staff who wrote it. This should not be the case because an informed consent is a legal document of an incident that took place. The purposes of an incident report are the following:

• To document the exact detail of an accident or unusual incident that occurred in a health-care institution.
• To be used in the future when dealing with liability issues stemming from the incident.
• To protect the nursing staff against unjust accusation.
• To protect and safeguard the client in case of negligence on the part of the nurse.
• Helps in the evaluation of nursing care to ensure safe care to all patients.
• Written at the first opportunity after the incident so that the details are not blurry or forgotten.
• Written with a pen (ink) not pencil. Information written using a pencil can be erased.
• Details should be complete and accurate. The patient should be identified with the following details:
• Hospital bed number
• Hospital ID
• Patients diagnosis
• Patient’s condition before and after the incident

Other details included are:

• Details of ward or clinical area
• Date, time and place of incident
• Details of equipments used including the serial number or asset tag identification (if appropriate)
• Written as statement of facts without interpretation or opinion. Descriptive adjectives should not be used.

For example instead of writing:

“Mr. Dimaano would not listen when I told him to stay in bed. He is very difficult to care for. It is his fault why he fell on the floor.”

You should write:

“I heard a loud crash, and immediately went to the ward. I found Mr. Dimaano on the floor.”

• Events should be written in sequence that they occurred.
• Proper technical terms should be used. For example instead of using the word bottle specify that it is a urinal.
• Identifies the witnesses.
• Identifies the medications given before the incident (if applicable)
• Identifies the equipment that is involved or used.
• Signed legibly with the correct designation.

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5 Key Incident Reporting Example Scenarios in Healthcare

Incident reporting example  scenarios are pivotal in understanding the critical role of incident and event documentation within healthcare. Through meticulous analysis, these examples highlight how reporting is fundamental in preventing the recurrence of safety events. It empowers healthcare professionals to capture, analyze, and disseminate crucial data effectively, promoting a culture of proactive risk management. Read on for five incident reporting examples , each demonstrating the strategic value of implementing a robust incident management process.

Incident Reporting Example Scenarios in Healthcare

1. medication errors.

Medication errors are a significant concern in healthcare, with common reasons for errors including:

• Failure to communicate drug orders
• Illegible handwriting
• Confusion over similarly named drugs
• Errors involving dosing units or weights.

A study analyzing medication errors from 2019 to 2021 found that 99.7% of reported incidents were classified as near misses . This high rate of near misses underscores the importance of immediate action when a medication incident occurs.

Following an error, it’s crucial to inform a doctor immediately, who should then review the patient and determine if any remedial treatment is required. Additionally, the patient should be informed of the incident. To further enhance patient safety , healthcare organizations should aim to proactively eliminate medication errors by investigating both errors that have occurred and identifying their root causes so corrective action can be taken to prevent similar errors from happening again.

In a typical hospital setting, a scenario involving medication errors might unfold as follows:

A vigilant nurse detects a potential medication error before administration to the patient. Understanding the critical nature of such near misses, the nurse expeditiously files an incident report using the hospital’s incident management system .

This action initiates an immediate and rigorous inquiry by the hospital’s patient safety team. Their investigation delves deeply into the underlying causes of the error, ultimately uncovering a systemic flaw in the medication dispensing procedure that leads to ambiguity among the nursing staff.

To address this issue, the hospital adopts a series of targeted corrective actions. These include comprehensive staff training programs, refinement of existing processes, and the implementation of more robust communication protocols, all aimed at preventing future medication errors and enhancing overall patient safety .

2. Patient Falls

Patient falls are unexpected events that can affect patient safety , often resulting in injuries such as fractures, lacerations, internal bleeding, or even death. These incidents are typically documented in a detailed report which outlines the chain of events leading up to and following the fall.

After a fall, immediate evaluation and monitoring of the patient is crucial, including a review of the patient’s symptoms and description of injuries. Incident reporting software allow for these analyses to easily take place.

For instance, the Affiliated Hospital of Nantong University conducted a retrospective analysis of fall incidents using its database and non-punitive reporting system for adverse events. Another health system in the United Kingdom used its incident reporting tool to study the incidence and characteristics of inpatient falls among patients under enhanced supervision.

As for a full incident reporting example , imagine a patient experienced a near-fall due to a wet floor near the nurse’s station. The nurse then submits an incident report using the hospital’s incident reporting system. This triggers a rapid response from the patient safety committee, which conducts a comprehensive investigation.

The analysis reveals issues with the environmental safety protocols and the need for enhanced monitoring in high-risk areas. In response, the hospital can implement corrective actions , including increased signage, regular environmental safety checks, and additional staff training on fall prevention strategies.

3. Surgical Complications

Surgical procedures come with inherent risks, but complications can sometimes arise due to human error, equipment failure, or unforeseen circumstances. These incidents could range from retained surgical instruments to wrong-site surgeries.

Robust incident reporting in these scenarios is crucial for analyzing the entire surgical process, from pre-operative assessments to post-operative care. There is significant concern about the under-reporting of surgical complications , as the incidence of postoperative complications is a frequently used marker of surgical quality.

To visualize an incident reporting example : A patient experiences an unexpected postoperative complication following a routine surgery. The surgical team promptly initiates an incident report which triggers an immediate response from the hospital’s quality improvement team. This team conducts an investigation into the root causes of the complication .

The analysis reveals a communication breakdown during the preoperative assessment and a need for improved monitoring during the recovery phase. The facility then knows how to respond by implementing corrective measures.

4. Communication Breakdowns

Breakdowns in communication can lead to adverse events and harmful consequences.

For example, a recent study of a major health system found that during the diagnosis process in the emergency department (ED), 23% of patients did not receive an explanation of their health problem upon discharge, and one-quarter of those patients did not understand the next steps after leaving the ED, including what to do if a condition were to get worse or didn’t improve.

In cases like these, patients might leave without understanding their diagnosis or the next steps in their care, leading to confusion and potential health risks.

When communication touchpoints are not optimal or are missed altogether, there is an opportunity for harm. Incident reporting in healthcare is a key tool for identifying and addressing these breakdowns, fostering a culture of safety through frequent and candid communication among providers and staff.

Picture a miscommunication during the handover between nursing shifts that led to a delay in administering critical medication. Recognizing the potential impact on patient care, the nursing staff promptly submits an incident report which leads to a swift response from the hospital’s patient safety committee to conduct an analysis.

The investigation reveals gaps in the handover process, including unclear documentation and inconsistent communication practices. In response, the hospital can implement targeted corrective actions, such as standardized handover protocols, regular communication training for staff, and the incorporation of technology to enhance communication efficiency.

5. Patient Misidentification

Patient misidentification incidents are commonly reported in healthcare settings, with the most frequent errors being missing wristbands, wrong charts or notes in files, administrative issues, and incorrect labeling. Contributory factors to these incidents often include system failures and human error. These errors can often be easily avoided but when they occur, they have a serious negative effect on patient safety .

Incident reporting systems are used to identify and characterize these critical incidents, and to prevent their recurrence.

To picture incident reporting examples dealing with patient misidentification, consider a patient receiving a lab test intended for another individual due to an identification error during registration. Recognizing the potential consequences, the healthcare worker swiftly submits an incident report. This prompted an immediate response from the hospital’s patient safety team, initiating a thorough investigation into the incident.

The analysis reveals issues in the patient identification process, including reliance on similar-sounding names and inadequate verification protocols during registration. In response, the health system understands what corrective measures to implement, including the introduction of unique patient identifiers, staff training on meticulous identification procedures, and regular audits of registration processes.

Incident reporting is not about assigning blame but rather about creating a culture of transparency, learning, and continuous improvement within healthcare organizations. By examining these five key incident reporting examples in healthcare, it becomes evident that a robust reporting system is essential for enhancing patient safety and overall healthcare quality.

Healthcare professionals must view incident reporting as a proactive tool and an opportunity to identify system weaknesses to implement changes that will prevent similar incidents in the future. As the healthcare landscape continues to evolve, fostering a culture that prioritizes incident reporting and embraces a commitment to learning from mistakes is crucial for the betterment of patient care and safety.

Ready to get started?

Begin your journey towards better incident reporting today. Connect with our team to learn more about Performance Health Partners’ industry-leading incident management system .

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Top 10 tips for statement writing

You could be asked to write a statement for an investigation at work, in response to a complaint, or about an unexpected incident. These are the main points to consider

• Don’t rush . You should never have to write and submit a statement immediately.  It’s fine for an employer to set a deadline, but you should still have reasonable time to prepare your statement and get it checked by the RCN. 
• Know what you’re writing about. You should be given a clear instruction or question in writing. If you haven’t been given this, ask for it.
• Consider if you’re at risk. If your conduct or practice is being questioned by your employer or agency, then – provided you were a member at the time of the incident – use the RCN’s statement checking service accessed via RCN Direct on 0345 772 6100. If you’re being asked to provide a statement purely as a witness, and you don’t believe there is any risk to you, simply follow our guidance  – we don’t need to check it.
• Be clear. Your statement should explain events from start to finish as clearly and simply as possible. Explain when things happened, who was there, and what you did, saw and heard. Try to avoid offering an opinion not based on facts.
• Be relevant . Do your best to answer the question or allegation you have been set. If you can’t remember something, say so. Very few people can perfectly recall every event that’s ever happened to them.
• Be compliant. If you’re a registered nurse, follow the NMC Code of Conduct, particularly the ‘Promote professionalism and trust’ section. Ensure you follow your employer’s local policies and confidentiality guidelines too.
• List all documents referenced in your statement. If possible, state where to find them.
• Format your statement. Add page and paragraph numbers, double space your lines and ensure pages have clear wide margins at each side.
• Check it. Review each paragraph carefully, checking that your statement only communicates exactly what was asked for or required. Look at whether you can provide evidence for the facts stated. Check the facts you provide are clearly and objectively explained.
• Keep a copy. You may need to refer to it in the future. 

The RCN’s statement writing guidance  covers these tips in more detail, has a statement writing template you can use, and provides guidance on what to do if you are asked for a statement in other contexts such as if a coroner or the police ask you for a statement.

• Avoid general sentences like ‘500mg of paracetamol was given’ or ‘observations were made’. Instead state who gave the paracetamol, who made the observations, and what observations were made. Avoid jargon, as people reading your statement may not understand it. 
• The identities of patients and members of the public should be kept anonymous. For example, use ‘Patient X’ throughout the statement.

Why is this so important?

"Handing in a poor statement can be the difference between resolving an investigation or things being escalated to a disciplinary or NMC hearing," says Nathan Arthur from the RCN's statement checking team. 

"Not having a clear or relevant statement means that you might be asked to write another, attend an investigation meeting or the investigation is escalated further. 

"A non-compliant statement, such as where information is provided which could identify a patient or member of the public could, in and of itself, lead to serious action to be taken against you by your employer and the NMC."

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Incident Reporting in Healthcare: A Complete Guide (2024)

Abishek goda.

• May 13, 2021

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An incident is an unexpected event that affects patient or staff safety. The typical healthcare incidents are related to physical injuries, medical errors, equipment failure, administration, patient care, or others. In short, anything that endangers a patient’s or staff’s safety is called an incident in the medical system.

The process of collecting incident data and presenting it properly to action is known as ‘Incident Reporting in Healthcare.’ With incident reporting, an emerging problem is highlighted in a non-blaming way to root out the cause of the error or the contributing factors.

Designated staff with authority to file a report, or staff who has witnessed an incident firsthand, usually file the incident report in the hospital. Usually, nurses or other hospital staff file the report within 24 to 48 hours after the incident occurred. The outcomes improve by recording incidents while the memories of the event are still fresh.

When To Write an Incident Report in Hospital?

When an event results in an injury to a person or damage to property, incident reporting becomes a must. Unfortunately, for every medical error, almost 100 errors remain unreported. There are many reasons for unreported medical incidents, but not knowing when to report is one of the most common ones. 

Unfortunately, many patients and hospital employees do not have a clear idea about which incidents to report. Knowing when to report in hospitals can boost safety standards to a great extent.

Let’s consider these situations:

✅ A nurse is helping a patient walk from his bed to the bathroom. However, he stubs the big toe on his left foot on the IV pole that he is dragging.

✅While injecting the accident patient’s IV with pain medication, the nurse misread the label and administered a heavier dosage than prescribed, which increased the patient’s blood pressure level. 

In these situations, it is necessary to fill in the incident reports in hospitals. Simply because an unexpected event occurred and led to harm, it doesn’t matter how severe or minor the incident is. It is essential to report all incidents.

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This free eBook offers a comprehensive RCA guide for healthcare, including team selection and action plan development. Download now!

The Purpose of Incident Reports in Hospitals

Incident reports provide valuable information to hospital administration facilities. They capture data required to highlight necessary measures to improve the overall safety and quality of the hospital. An accurate incident report serves multiple purposes.

1. Root Cause Identification

All incidents have a cause. Mishaps are pretty uncommon in hospital settings, and most incidents can be root caused by a potential reason. Correcting the root causes can easily avoid future incidents of that type. In this sense, root cause analysis of an incident is an essential investigation step for all hospitals to ensure their staff and patients are safe under most conditions.

2. Policy and Process Improvements

Some incidents are part of a larger pattern that can only be identified by looking at them together – let’s say, for example, through a Swiss cheese analysis model. Such assessments usually identify more significant issues that aren’t immediately apparent from individual incident reports or investigations. These assessments feed into clinical risk management as well as help guide the hospital administrators to tweak their policy or process guidelines to help staff adhere to a safer care routine. 

For example , let’s take a pattern of incidents. Each has a root cause individually to what looks like a handover issue – but at different stages or different type of facilities. It would be possible to tweak each of these handover processes individually to fix that specific issue. However, it may be more productive to improve the overall handover process by taking all the incidents as a whole and tweak to address them together.

3. Clinical Risk Management

All hospitals have and use their enterprise risk management processes. Clinical risk management, a subset of healthcare risk management, uses incident reports as essential data points. Risk management aims to ensure the hospital administrators know their institution’s performance and identify addressable issues that increase their exposure. And the ability to assess clinical risks ensures the hospitals can stay ahead in their business and provide high-quality care and a safe workplace for all staff.

4. Continuous Quality Improvement (CQI)

All hospitals have continuous improvement plans that help them stay updated with all the latest developments in patient safety and quality by assessing, evaluating, and improving their processes and methods over time. Having incident reports duly filled and followed up to closure helps the CQI process to identify potential areas of improvement and help the organization achieve a more successful CQI cycle that takes them forward.

5. Better Training and Continuous Learning

Incident data are essential sources of knowledge and on-the-job training material. Incident investigation is a rich source of information that will help new staff understand why the hospital has a specific process that may differ from their previous workplaces. Similarly, having a robust incident management system helps implement a good continuous learning program for the staff that helps them learn the most important details they need to be efficient in their day-to-day work.

Types of Incident Reports in Healthcare & Hospitals

In healthcare, an incident is an unfavorable event that can take various forms depending on specific circumstances. Broadly, there are four types of incidents and incident reports in hospitals:

• Clinical Incidents
• Near Miss Incidents
• Non-Clinical Incidents
• Workplace Incidents

Understanding these distinct incident types is essential for healthcare professionals and organizations to ensure patient safety and quality care.

• Clinical Incidents: A clinical incident is an unpleasant and unplanned event that causes or can cause physical harm to a patient. These incidents are harmful in nature; they can severely harm a person or damage the property.
• Near Miss Incidents: Sometimes an error/unsafe condition is caught before it reaches the patient. Such incidents are called “near-miss” incidents. However, the problem might have diffused before the severe harm, but it is still essential to report near-miss incidents. Nearly 50 near-miss incidents occur for each injury reported.
• Non Clinical Incidents: Non-clinical incidents include events, incidents, and near-misses related to a failure or breach of EH&S, regardless of who is injured or involved.

Workplace Incidents: A work accident, occupational incident, or accident at work is a discrete occurrence that can lead to physical or mental occupational injury. The workplace incidents are related to mental as well as physical hurts. According to the BLS’s Workplace Injuries and Illness News , nursing assistant jobs have the highest incidence rates.

Examples of Incidents in Healthcare & Hospitals

In healthcare, incidents range from clinical errors like wrong medication administration to near-misses like catching medication errors before harm. Non-clinical incidents include misplaced documentation, while workplace incidents involve safety issues like patient abuse or needle pricks. These incidents underscore the importance of rigorous protocols and a supportive work environment.

• Nurse administered the wrong medication to the patient.
• Unintended retention of a foreign object in a patient after a surgery.
• Blood transfusion reaction.

Near-miss incidents in hospitals:

A nurse notices the bedrail is not up when the patient is asleep and fixes it. 

A checklist call caught an incorrect medicine dispensation before administration.

A patient attempts to leave the facility before discharge, but the security guard stopped him and brought him back to the ward.

Non-clinical incidents in nursing homes:

Misplaced documentation or documents were interchanged between patient files. 

A security mishap at a facility.

Workplace incidents in hospitals:

Patient or next-of-kin abuses a care provider – verbally or physically – leading to unsafe work conditions. 

A healthcare provider suffered a needle prick while disposing of a used needle.

Examples of Incident Report Form in Healthcare & Hospitals

Example of m edication error incident report form.

• Date : [Date]
• Time : [Time]
• Location : [Ward/Room Number]
• Patient Name : [Patient’s Full Name]
• Medical Record Number : [Patient’s MRN]
• Description of Incident : A medication error occurred when [Nurse’s Name] administered [Medication Name] to the patient. The prescribed dose was [Prescribed Dosage], but the patient received [Administered Dosage]. The incident was discovered at [Time] when the patient experienced [Describe Any Adverse Reactions or Symptoms].
• [Nurse’s Name] immediately informed the charge nurse and physician.
• [Describe Any Interventions or Treatments Given].
• Incident reported to pharmacy for review and documentation.
• Family informed of the error.
• Root cause analysis to be conducted to prevent future occurrences.

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Patient fall incident report form example

• Description of Incident : Patient [Patient’s Name] fell in their room while attempting to get out of bed. The incident occurred at approximately [Time]. The patient sustained [Describe Any Injuries].
• [Nurse’s Name] responded immediately, assessed the patient, and called for assistance.
• Patient transferred to [Location] for further evaluation and treatment.
• Physician notified.
• Fall risk assessment to be conducted, and appropriate interventions to prevent future falls to be implemented.

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Who Prepares Incident Reports in Hospitals?

At QUASR , we believe all staff (and patients, too) should be able to report incidents or potential incidents they have witnessed. But in practice, it is a bit different. Some hospitals have designated persons who are authorized to file the reports. In some other hospitals, the staff usually updates their supervisor about an incident, then can file the report. 

QUASR clients, usually, have configured to give access to all their staff so that they can initiate an incident report enabling them to stay aware of all the issues that occur – however minor or inappropriate it may be. Allowing all staff to report requires a training effort from the quality and safety teams to ensure all the employees understand what and when to file an incident report

Critical Components of Incident Report in Healthcare

One comprehensive incident report should answer all the basic questions — who, what, where, when, and how. Most hospitals follow a preset reporting format based on their organizational needs. However, an incident report must cover the following aspects:

1. General Information

The well-informed incident report needs basic information such as the date and time of the incident. Additionally, for future analysis, your report must include general information.

2. Location of the Incident

Specifically, mention the location of the incident and the particular area within the property—for example, patient X fell in Ward no. 2 near the washroom. With the location specifications, administration staff can better investigate the reason behind the incident and fix it.

3. Concise yet Detailed Incident Description

The incident description needs to be clear and meaningful — don’t use vague language, never add baseless information, and keep personal biases out. Whenever you have to add your opinion to the report, mark it as an assumption or subjective opinion.

4. Type of the Incident

You should define the nature of the incident while reporting to get a clear view. We can categorize the hospital incidents into different types such as Medication Error, Patient Fall, Equipment Damage, Abuse, Pressure Ulcer, Radiation, Surgery/Anesthesia, Laboratory related, Security, Harassment, Loss or damage to property, Patient Identification, among others. QUASR offers 25 such incident types built-in by default.

5. Information of all Parties Involved in the Incident

The administration needs the name and contact details of all the parties involved in the incident. The report should capture all the relevant information required to follow up with the involved parties.

6. Witness Testimonies

If there are witnesses available to the incident, it will be helpful to add their statements in your report. While writing witness statements, focus on the following attributes — specific details provided related to the incident, use quotation marks to frame their accounts, note witnesses’ location at the time of the incident, and how they are related to the incident.

7. Level of Injury

In case of injury, the reporting staff must record the injury level and cause in the report. If the incident involves an in-patient at the hospital, their medical records will reflect the treatment and diagnosis of the injury. However, for others, it might be required to follow up and record their injury diagnoses.

8. Follow Up

The incident report is incomplete without the follow-up action details. Each report should include remarks stating what preventive measurements and tactics you have opted to avoid such incidents in the future.

Once a final follow-up on the incident report is made, the next phase is reviewing. In this step, the supervisor or manager ensures the implementation of corrective actions against the report. The goal of the review is to prevent the recurrence of the incident and create immediate action plans. While reviewing incident reports, a reviewer should consider the following things:

SBAR abbreviates S ituation, B ackground, A ssessment, and Recommendations. The reporting person’s supervisor at the time of the incident typically performs SBAR. SBAR attempts to capture more structured information about the incident, what happened, pre-conditions leading to the incident, information about the patient or staff, if involved, a first assessment of what caused the incident, and recommendations for follow-up or corrective actions.

11. Risk Scoring

A risk score is a calculated number that reflects the severity of risk due to some factors. We compute risk scores as a factor of probability and impact. It is common in the industry to use a 5×5 risk scoring matrix. But there are other methods too, and sometimes the scoring changes based on the type and nature of the incident.

12. Investigation Information

An investigator or an investigation team needs to go through all the supporting evidence to analyze the incident. The incident supporting comes in different forms, such as photos, CCTV footage, and witness statements. It is essential to verify the supporting evidence during an investigation. Information investigation often leads to:

13. Root Cause Analysis

Root cause analysis is a problem-solving method used to identify the root cause of the problem. The typical output of the RCA step is a set of contributing factors that then indicate systemic issues that may be addressed together by policy or process changes.

Standard RCA tools used in the industry include the Five Why method, Ishikawa, or the Fishbone Analysis. Some cases use more advanced techniques like the Swiss cheese model or PRISMA .

14. Contributing Factors

Contributing factors are those factors that influenced a single event or multiple events to cause an incident. If contributing factors are accelerated, it will affect the severity of the consequences. Therefore, with the knowledge of contributing factors, management can eliminate them to prevent similar incidents from occurring in the future.

QUASR implements a form of the London Protocol for capturing these factors.

15. Executive Summary

The compelling executive summary is the final step in reporting incidents. It is a short document produced for management purposes. It summarizes a more extended report so that readers can quickly become acquainted with the material. Management can get a crisp reading of the incident from the executive summaries without reading the entire report.

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Benefits of Incident Reporting in Hospitals

Through healthcare data analysis, setting the correct key performance indicators in your organization becomes simpler. Here are some vital benefits that you can gain from incident reporting in hospitals.

1. Preventive Measures

One of the most powerful elements of an incident report is streamlining historical and current data to spot potential incidents in advance. Using predictive analysis, healthcare facilities can improve the quality of patient care and reduce workplace mishaps. Around 60% of healthcare leaders have confirmed that adopting predictive analytics has improved their efficiency considerably.

2. Disease Monitoring

Disease monitoring is one aspect of the first predictive analytics. With the incident reports, healthcare organizations can monitor potential disease outbreaks by using past and present metrics. 

During COVID-19, many hospitals have struggled to prevent disease outbreaks on their premises. But, the organizations that have insightful data with them may have managed the pandemic outbreak a lot easier.

3. Cost Reduction

Reporting can also make healthcare operations more economically effective. By gathering and analyzing incident data daily, hospitals’ can keep themselves out of legal troubles. A comprehensive medical error study compared 17 Southeastern Asian countries’ medical and examined how poor reporting increases the financial burden on healthcare facilities.

4. Enhanced Patient Safety

Improving patient safety is the ultimate goal of incident reporting in hospitals. From enhancing safety standards to reducing medical errors, incident reporting helps create a sustainable environment for your patients. Eventually, when your hospital offers high-quality patient care, it will build a brand of goodwill.

Healthcare Incident Reporting Challenges

Healthcare incident reporting has various managerial and safety-related benefits. To create a result-driven incident report, you have to cross the next hurdles also:

1. Paper-based Reporting

In this technology era, many healthcare organizations still rely upon traditional paper-based reporting. Paper-based reporting is a manual approach where the incident details are recorded and managed using paper and often hand-written reports.

Paper-based reporting has numerous disadvantages, including low-quality data, limited flexibility, costly process, error-prone, time-consuming, and more. Get started digitizing your incident data by downloading our Excel-based Incident Reporting Template and quickly replace paper-based reporting. We even have a post explaining the Excel incident report template and how you can benefit from it.

2. Underreporting

The problem of underreporting is widespread in the healthcare industry. Common causes of underreporting include:

1) Lack of awareness about when and what to report.

2) Fear of repercussions from colleagues or seniors.

The reason behind underreporting might vary, but no one can deny that it is the biggest reporting challenge. We had written a detailed article on our assessment of under-reporting in our blog. According to the Agency for Healthcare Research and Quality , all healthcare facilities should offer a simple and anonymous reporting way to their staff. QUASR has built-in features to encourage reporting in a pseudo-anonymous manner encouraging staff to file a report without fear.

3. Busy Schedule

The busiest hospital personnel, nurses, and doctors are mainly responsible for filing incident reports. Due to their busy and often overworked schedule, they sometimes fail to report incidents. A solution must factor in this constraint at the time of design and implementation to ensure all incidents are recorded in a timely fashion without over-burdening the staff.

After understanding the purpose, benefits, and challenges of incident reporting in healthcare, it is clear that reporting is essential for medical facilities. Whether you wish to improve patient safety or reduce workplace mishaps, incident reporting can serve multiple purposes. But, compiling, reviewing, and investigating incidents in a timely and unbiased fashion isn’t a simple task. 

You require an automatic hospital incident reporting system  to manage hundreds of incidents at any given time. We can say that QUASR has practical tools to help you create track-analyze incident reports. QUASR – healthcare incident reporting software is easy to use and access, which allows fast and accurate incident reporting.

We have various elements in our software for resilient healthcare incident reporting ensuring all the best practices. To better understand what QUASR can do for you, book a free demo today . 

Also, stay connected with us as we will be covering more topics related to digitalized incident reporting.

Meanwhile, feel free to contact us for further information!

Contact us to find out how QUASR helps hospitals and nursing homes with  digitalized incident reporting.

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