Incident Report in Nursing: Definition and Examples

By Winona Suzanne Ball, RN, MHS

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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:

1. 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.
2. 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.
3. 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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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:

1. Your name and title
2. Date and time of the incident
3. Exact location of the incident

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

1. Current observations about the incident area
2. Witness full names and contact information
3. Witness statements

Actions and Recommendations

1. Actions that you took to give aid
2. Actions that you took to prevent further injury/damage
3. Recommendations to prevent another event

1. 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.

• 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