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.
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:
The following elements should be included in your nursing incident report:
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.
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.
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:
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.
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.
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.
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.
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.
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.
Follow these steps to help you write an effective nursing incident report.
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:
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.
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.
Determine the outcome of the incident. If people were injured, write down the nature of those injuries and provide the following details:
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.
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.
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.
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:
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.
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.
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.
Dos
Don’ts
Related:
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.
NurseMyGrades is being relied upon by thousands of students worldwide to ace their nursing studies. We offer high quality sample papers that help students in their revision as well as helping them remain abreast of what is expected of them.
Get Help
