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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.

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How Can I Obtain a Nursing Home Incident Report?

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Obtaining a Copy of the Nursing Home Incident Report

Nursing homes are legally required to create an incident report following any serious injury or allegation of abuse. State regulations and federal guidelines via CMS, mandate that after a serious event occurs, the facility must conduct an internal investigation. Following the internal investigation, an incident report is created.

Most state laws allow for the victim, or the victim’s family, to view a copy of the nursing home incident report.

Common Injuries That Trigger an Incident Report in a Nursing Home

Regardless of the alleged explanation, these injuries usually result in an incident report being created:

* Falls resulting in broken bones * Falls resulting in brain bleed * Unexplained broken bones  * Stage 4 bedsores * Broken hips  * Unexplained bruising * Elopement from the building

Common Abuse Allegations that Trigger Mandatory Incident Reporting

Similarly, nursing homes are legally required to investigate these allegations of abuse:

* Sexual abuse * Physical abuse * Theft * Emotional torment

These incidents require facility investigation, regardless of whether the abuser is a fellow resident, or a staff member.

What Information is Contained in a Nursing Home Incident Report?

Nursing homes are supposed to get the entire story of all participants involved in an adverse incident involving a patient. This means the incident report should have the statements of all staff and witnesses to the event.

For example, let’s say a bedbound resident is rushed to the emergency room with a broken hip and left flank bruising. The hospital radiologist concludes that the fracture occurred from trauma, like a fall, but this victim cannot even walk. Clearly, something happened at the nursing home. This should trigger a nursing home investigation and corresponding incident report.

In this hypothetical nursing home incident report, the report should contain the statement of the aide that transfers the resident, the supervising LPN that saw the aide rush out of the room suspiciously, the Med Tech that heard a loud thump when she walked past the room, the Director of Nursing that received an anonymous tip on what really happened, and anyone else who heard something about the incident. The investigation would include damning admissions from facility staff on what they believe happened, and highlight any inconsistencies in the staff’s story.

Ultimately, the nursing home incident report would likely conclude that the resident was being transferred and was dropped by the aide . Further, the incident report should conclude that the resident’s injury was intentionally concealed, and the guilty staff member should be fired immediately.

Transparency in Nursing Home Reporting Data

There is a general trend towards disclosure of nursing home reporting information. In the 90’s, the federal government mandated publishing nursing home citations and deficiencies. We now have more than two decades of data on nursing home care failures ( In 1998, the first version of the Nursing Home Compare website was launched with information limited to nursing home regulatory deficiencies). This allowed access to anonymized deficiencies, where the injured resident was called ‘Resident 3’, and not by name. So if the incident made it into a survey, you may be able to find out the nursing home’s take on what happened through a publicly available nursing home survey citation. 

However, this is far from a sure thing. Additionally, there is lag time in CMS survey reporting, and survey citations do not capture the majority of adverse events that occur inside a skilled nursing facility. Inspectors only catch what they happen to stumble upon when visiting the facility on an unannounced spot check.

The best account of what happened will be a nursing home incident report. If the injury or incident was serious enough, the nursing home is legally been required to create an internal adverse incident report. You, as the patient’s legal guardian, should be entitled to view that report. Unfortunately, without legal counsel, most families have a hard time getting a nursing home’s incident report.

Why Can’t I Get the Nursing Home Incident Report?

Simply put, the nursing home does not want you to see the incident report!

Take a look at what the above hypothetical adverse event report would contain. This would likely result in punitive damages against the offending nursing home. This is why nursing homes will do everything they can to withhold producing the incident report to family members.

Nursing home management will do everything they can to keep you from seeing the incident report because, oftentimes, it will lead you to sue the facility for negligence.

How Can I Get a Nursing Home Incident Report?

Nursing home incident reports are usually created pursuant to a skilled nursing regulation . In the majority of states, the law requires production of nursing home incident reports in litigation, even if the nursing home incident report itself is not admissible as evidence.

Unfortunately, angry letters and demands for fairness will get you nowhere. In order to obtain a nursing home incident report, you will need an experienced and skilled nursing home abuse attorney in your corner.

At Senior Justice Law Firm, our entire firm focus is on nursing home negligence. This is all we do. We regularly obtain nursing home incident reports in litigation through discovery. When a nursing home objects to producing an incident report, we go to court and get a judge to sign an order compelling production of the investigation.

Is it Expensive to Retain a Lawyer to Get a Nursing Home Incident Report?

No. Our nursing home abuse attorneys work entirely on contingency fee. This means you never have to pay us a dime out of pocket. We only get paid if we win your case and recover money for you.

Free Nursing Home Incident Report Legal Consultation

You would not try to diagnose an illness without a doctor. When your car breaks down, you go to a mechanic. Do not try to traverse complicated legal avenues without the help of an experienced attorney.

Our firm focus is on nursing home negligence claims. We have obtained hundreds of nursing home incident reports for families, even after they were told it was “only for internal use inside the nursing home.” We can help you and your family.

If your loved one suffered a serious injury or death inside a nursing home, contact Senior Justice Law Firm today. We can get you the answers and compensation you deserve following a terrible tragedy inside a facility. Submit your case facts below, or give us a call today to learn more about your legal rights after a nursing home injury or wrongful death.

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Are You Filing Incident Reports Properly?

Knowing when—and how—to file incident reports can help you to protect yourself, your patients, your colleagues, and your organization.   

When a situation is significant—resulting in an injury to a person or damage to property—it’s obvious that an incident report is required. But many times, seemingly minor incidents go undocumented, exposing facilities and staff to risk.   Let’s discuss three hypothetical situations. 

• You’re helping a post-op patient walk from his bed to the bathroom, and he stubs the big toe on his right foot on the IV pole he’s pushing. 
• When you check on an elderly patient recovering from a mild CVA, you find her on the floor, her left arm apparently fractured. She tells you she was looking for her dog. 
• In the process of reconstituting a vial of cefazolin (Ancef, Kefzol) to administer to a patient with pneumonia, you sneeze as you’re about to pierce the vial’s stopper to add sterile water, nicking your thumb with the needle. 

In which of these cases should you file an incident report?   The answer: all three.   An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required.  Many nurses complain that these reports are more trouble than they’re worth. Typically, the loudest outcry comes from nurses who sustain minimal injuries that do not affect anyone else but find that they must submit a report anyway. Before protesting the need to file an incident report for a seemingly minor event, consider the purposes incident reports serve.   Refreshing your Memory 

The medical record is patient focused, and facts pertinent to an unexpected incident will likely be left out. So if a claim were filed and the case proceeded to court, which sometimes occurs years after the event, you or anyone else involved might be hard-pressed to recreate the scene—especially if you consider it to be “minor” at the time. You may not be able to rely on memory alone, but you can count on the incident report to refresh your memory.    

Triggering a Rapid Response 

An incident report invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident. The report may also alert administration that a hospital representative should talk to a patient or family to offer assistance, an explanation, or other appropriate support. That’s an important function because such communication can be the balm that soothes the initial anger—and prevents a lawsuit. 

Facilitating Decisions about Restitution 

An incident report also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there’s no way to make these important decisions effectively.  

It’s Your Responsibility 

As a nurse, you have a duty to report any incident about which you have firsthand knowledge. Failure to do so could lead to termination. It could also expose you to liability, especially in cases of patient injury. Protect yourself and your patients by filing incident reports anytime unexpected events occur.   If you’re the one who discovers the incident, or you have been involved in the situation leading up to it and know more about it than your colleagues, filling out an incident report is your responsibility. You’re expected to complete it before the end of the shift during which the incident occurred or was discovered.   

Filling Out an Effective Incident Report 

In determining what to include in an incident report and which details can be omitted, concentrate on the facts.   Describe what you saw when you arrived on the scene or what you heard that led you to believe an incident had taken place. Put secondhand information in quotation marks, whether it comes from a colleague, visitor, or patient, and clearly identify the source.  Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected.   Add other relevant details , such as your immediate response—calling for help, for example, and notifying the patient’s physician. Include any statement a patient makes that may help to clarify his state of mind, as well as his own contributory negligence.   It’s equally important to know what does not belong in an incident report.    Opinions, finger-pointing, and conjecture are not helpful additions to an incident report.  Do not:  

• Offer a prognosis
• Speculate about who or what may have caused the incident
• Draw conclusions or make assumptions about how the event unfolded 
• Suggest ways that similar occurrences could be prevented.  

All Information in its Proper Place 

If a patient is involved in the event, keep in mind that entering your observations in the nurses’ notes section of the patient’s chart does not take the place of completing an incident report, and filling out an incident report is not a substitute for proper documentation in the medical record.  Record clinical observations in the chart—not in the incident report—and make no mention of the incident report in the patient record. The report is a risk management or administrative document and not part of the patient’s record. By including it in a patient’s record, lawyers may argue that the report is part of the medical record and should be turned over to the legal team.   

Incident Reports in Court 

If your facility undertakes an investigation of the incident in question, and you’re asked to speak to an insurance adjuster or attorney, be honest and factual. Fully disclosing what you know early on will help hospital administrators decide how to handle any potential legal consequences. It also preserves your testimony if you’re ever called upon to appear in court.   

Can an attorney enter incident reports into evidence? 

Whether a patient’s attorney can request and receive a copy of an incident report as part of the discovery process and introduce it into evidence in a malpractice lawsuit is subject to controversy. The law varies from state to state. In addition, there are steps facilities can take to avoid issues, like making the incident report an integral part of the internal quality assurance process and labeling it as such.   

Conclusion: Cover Your Bases. File a Report. 

Filing incident reports that are factually accurate is the only way to help mitigate potentially disastrous situations arising from malpractice and other lawsuits. It’s your responsibility to record unexpected events that affect patients, colleagues, or your facility, regardless of your opinion of their importance.  If the incident report has been filled out properly with just the facts, there should be no reason to be concerned about how it’s used. The danger comes only when incident reports contain secondhand information, conjecture, accusations, or proposed preventive measures that do not belong in these reports.   

To File or Not to File: A Few Common Occurrences 

Here are a few more incidents that may seem minor and common, but indeed require an incident report to be filed:  

• A visitor leaves a patient’s room and collides with a housekeeping cart left in the middle of the hallway.  
• A nursing student observing an EKG tripped over the machine’s electrical cord and cut her hand as she tried to stop the fall.  
• A confused patient took a tube of nitroglycerin ointment from an unattended medication cart and rubbed it on her leg in an attempt to ease dry skin. 

Have these or similar situations occurred in your facility? Did you file an incident report?  

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Frequently Asked Questions

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What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

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The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

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If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

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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

When should an incident report be completed and how should the report be written? In this article we’ll show you our best practices.

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Make healthcare audits easier with our application, like GGZ Drenthe did! Want to know more? Find out about it in our blog!

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Want to know more about the SIRE (Systematic Incident Reconstruction and Evaluation) method? Read all about this analysis method in this TPSC blog.

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What is an Incident Report in Nursing?

Nurses are on the front line of most healthcare events. They triage patients in the emergency department. They manage day-to-day care for inpatient cases. They are the eyes and ears of patient safety. So when incidents happen, a nurse may be directly or indirectly involved in reporting the event. But what is an incident report in nursing?

In this blog, we’ll talk about incident reports and where nurses make an impact not only on ensuring that healthcare organization leaders are informed but also how their facilities mitigate future medical errors and near misses.

What is an Incident Report in Healthcare?

An incident report is a formal document that records any unforeseen or adverse events occurring within a healthcare facility. The importance of incident reporting cannot be overstated, especially when it comes to upholding healthcare standards and adhering to regulations. It is important to properly complete and store these reports for at least five years for audit purposes and to comply with regulatory standards.

Incident reports serve not only as tools for internal review but are also required by entities such as the Occupational Safety and Health Administration (OSHA) for the timely reporting of incidents leading to death, significant injury, or hospitalization.

How Nurses Can File a Healthcare Incident Report

Like any healthcare provider, nurses have a duty to report any incident about which they have firsthand knowledge. Nurses are expected to file their report before the end of the shift in which the incident occurred. Failing to do so can result in termination, exposure to liability, and other punitive outcomes. According to Nurses Services Organization (NSO), these are best practices for nurses to follow when filling out an effective incident report:

• Describe what you saw when you arrived on the scene or what you heard that led you to believe an incident had taken place. Put secondhand information in quotation marks, whether it comes from a colleague, visitor, or patient, and clearly identify the source.
• Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected.
• Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient’s physician. Include any statement a patient makes that may help to clarify his state of mind, as well as his own contributory negligence

It’s equally important to know what does not belong in an incident report:

• Opinions, finger-pointing, and conjecture are not helpful additions.
• Offer a prognosis.
• Speculate about who or what may have caused the incident.
• Draw conclusions or make assumptions about how the event unfolded. 
• Suggest ways that similar occurrences could be prevented.  

Nurses Reap Benefits of Online Incident Reporting Systems

Every nurse will encounter medical errors and emergencies, which is why having an efficient, digitized incident reporting system helps to ensure information is promptly and accurately logged to improve safety.

Traditional paper-based methods lack the function and benefits that online platforms offer. These are some of the features that nurses appreciate:

• Speed and accessibility
• Automatic escalation
• Customizable forms
• Simplified evidence attachment
• Anonymity and transparency
• Enhanced data analysis
• Visibility for leadership
• Regulatory compliance

MedTrainer offers all the functions listed above in an all-in-one compliance solution for use by nurses and other healthcare providers. Enhance your compliance programs with digital incident reporting solutions for any size organization. Contact us to learn more.

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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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How to Write a Nurse Incident Report

You don’t have to be anxious about writing incident reports. Nursing staff often worry about how to get the report done and what information to include. Healthcare facilities are no exception to mistakes.

Medical errors are now the third leading cause of death in the United States and can pose a danger to patients’ safety and well-being. Although incident reports can be time-consuming, they are vital to patient care.

What is an Incident Report?

Either electronically or printed, an incident report gives detailed information about the events that led up to and following an unexpected situation in healthcare. It does not have to have caused a threat to patient safety or to employee safety. A patient safety incident is one that poses a danger to their safety.

All witnesses must complete incident reports within 24 hours. The majority of incident reports are completed by licensed nurses. Our online nursing essays writers are the best in writing incident reports.

Why Nurses Write an Incident Report?

Incident reports can be used to provide important safety information to hospital management and keep them informed about aspects related to patient care. Also, incident reports are written for the following purposes:

Risk Management. Incident Reports are used to identify potential risks and prevent future errors. Standard turnover procedures may be recommended for nursing staff in cases of frequent medical mistakes.

Quality Assurance. Quality Assurance. Quality control groups review incident reports identifying any indications that the patient received high-quality, patient-focused, affordable care.

Education tools. Incident reports can be used as training tools. Healthcare teams often use incident reports to help others avoid similar mistakes.

Examples of Incident Report Writing Cases

Nursing staff must complete an Incident report when they witness or are notified about an incident. below are some of the example cases where an incident report is necessary.

• Examples include adverse reactions and medication errors
• Examples include: falls, burns, and falls.
• Examples include: complaints and treatment refusal
• Example: An error almost happened but it was fixed immediately.

What Information is Included by Nurses in Incident Reports?

Our professional essay writing nurses advise that incident reports should contain the following information:

• Location of the incident
• Incident type
• Name of the victim

A written summary of what happened in the incident should have the following details.

• A chronological lists of the event details as they unfolded
• Witness statemenst of parties involved
• Injuries that resulted from the incident
• What actions were taken after the incident
• Was there any treatments given to the injured
• What are the contributing factors of the incident

Other critical information included in the incident report form:

• Names of those notified about the incident
• Suggestion provided in case of preventing a future incident

How to Write an Effective Incident Report

We now know how critical these incident reports can be. Here are six tips to help you create a thorough and effective report.

• Be clear and concise
• Use proper grammar and spelling
• Be objective and avoid assumptions
• Use direct quotes as narrated by witnesses and other relevant parties
• List the chronology of events as they happened
• Use short notes to rememeber key details
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• How to Write Incident Reports (with Samples)

When something bad happens in the workplace, employers usually want to know the details of how it happened in order to make decisions and appropriate actions regarding the matter. This is important, especially when considering the liabilities of the workers involved and how similar incidents can be avoided. It is, therefore, critical to write an accurate report about the incident for proper documentation. But how can you write a good incident report to cover all the facts? Here are a guide on how to make a good documentation and 3 samples to enlighten you.

How to Write a Good Incident Report

Before we show you an incident report sample, let's first study the characteristics of an effective incident report and how to write it.

1. An Incident Report Must Be Accurate and Specific

When you write an incident report, you must be specific and accurate about the details, not merely descriptive. For example, instead of writing "the old patient" , it is more accurate to describe him as "the 76-year old male patient" .

Good grammar, which includes correct word choice and proper punctuation, is important to make your incident report clear, accurate and professional. It is also best to write in an active voice, which is more powerful and interesting than the passive voice.

2. A Good Incident Report Must Be Factual and Objective

Sometimes people tend to talk about their opinions and beliefs, rather than stating the facts. If you must include an opinion in your report, it is best to state it with the similar description that appears on some incident report samples: "In my opinion, there were too many people in the overloaded bus. In fact, there were 80 persons inside, when a bus of this size is only allowed to carry 70 individuals."

Besides, you must avoid including words that might connote something that changes the tone of your report. If you have to include statements from a witness or other people, you must clarify that you are quoting someone, and the words you used are not your own.

3. A Good Incident Report Must Be Complete and Concise

State all facts regarding who, what, when, where, how and why something happened without leaving out important details. Another person who reads the report must be able to get answers to his or her questions about the incident from your report. How many details to include may depend on their relevance to the incident and the policies of your department.

Your incident report may be needed in court someday and you should be prepared to be questioned based on your report. So the more details you have on your report, the less you have to depend on your memory and the more credible you are. However, confidential details must not be made public, such as a patient's personal information, which must be written somewhere safe.

4. A Good Incident Report Must Be Well-Organized

An incident report should be easily understood and not be confusing to the reader. How a report is organized depends on the complexity of the incident and the type of report being written. Usually, writing in chronological order is the simplest way to organize a report. However, an inspection incident report may be written by enumerating details according to findings.

5. A Good Incident Report Must Be Clear

Your incident report must be clear and do not contain ambiguities. It's a clear report if different people read the same report and come up with similar interpretations. Aside from writing in detail, you can also use sketches, diagrams and photos to complete your report.

6. A Good Incident Report Must Only Include Proper Abbreviations

The use of abbreviations may be appropriate in certain cases, such as the use of Dr. Brown and Mr. Green, instead of writing Doctor or Mister. However, it is not proper to write something like "I talked to the dr. (doctor) about what I should say to the pt. (patient)."

3 Different Incident Report Samples

Here are three different incident report forms for you and try to fill in by yourself. When you do this, please bear all the 6 rules above in mind.

Laboratory Incident Report

Hospital Incident Report

Client Incident Report 

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Nurse Incident Report

Incident report generator.

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

1. school nurse incident report.

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2. Confidential Nurse Incident Report

Size: 18 KB

3. Basic Nurse Incident Reporting

Size: 259 KB

4. Nurse Incident Report in PDF

Size: 279 KB

5. Nurse Incident Response and Reporting

Size: 144 KB

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

• Instructive
• Professional

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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Documenting and Reporting Incidents in the Workplace

• Written by Zach Smith, BSN, RN

As a nurse, it’s your job to document and report any incidents that might occur when caring for patients. From accidents to patient complaints, a lot can happen when you’re spending time with a patient. It’s your responsibility to pass that information along to your supervisors and medical personnel using incident reports. Learn more about documenting incidents in the workplace and how you can use new technology to your advantage.

What Is an “Incident” and Why You Should Report It

In the field of nursing, an incident is generally described as a situation in which something out of the ordinary occurs. While this definition is vague, nurses are often directed to use their judgement. What qualifies as an incident varies depending on the facility in question.

Incidents usually fall into one of these categories:

• Someone, either you, the patient or a visitor, is injured, or a situation occurs with the potential for injury (i.e. a patient slips and falls, or you prick your finger when drawing the patient’s blood)
• A medication error occurs in which the patient missed their medication or took the wrong pill
• A medical device malfunctions and needs to be repaired or replaced
• The patient has a complaint about their experience at the facility

Remember to use your judgement when caring for patients and be on the look out for anything out of the ordinary. If you make a mistake while caring for the patient, don’t be afraid to report the mistake. Being honest and accurately documenting your experiences on the job are part of your responsibility. When in doubt, put yourself in the shoes of the doctor or facility manager and ask yourself if this information is something they need to know. You can always ask your supervisor or manager if the incident needs to be reported.

Over time, you will learn what qualifies as an incident, so you can do your job quickly without always second-guessing your instincts.

New Documentation and Incident Reporting Technology for Nurses

Thanks to improvements in healthcare technology, documenting and reporting incidents on the job has become much easier than it used to be. Instead of cumbersome paper forms, nurses can now upload incident reports to a patient’s file using electronic health records and special digital incident forms. You can quickly select the particular type of incident report you need, enter some key information into the computer, and attach the report to the patient’s file.

Using these automated digital forms makes it easier to manage and organize incident reports. If an incident occurs on the job, you or your supervisor can quickly search for the patient’s record and see the details of what happened. These digital forms are also easily sharable. If a patient is transferred to another department or wing of the facility, you can pass off their information, including all incident reports, to the patient’s new healthcare provider. You and your supervisors don’t have to worry about valuable information getting lost in the shuffle.

Use digital incident reports to keep track of your experiences with the patient to make sure everyone has the information they need to deliver the best possible care.

• Published: January 21, 2019

Zach Smith, BSN, RN

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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.

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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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Brittany has a Bachelor's of Science in Nursing as well as Biological Sciences.

Table of Contents

The swiss cheese model, how to complete an incident report, learning from mistakes, lesson summary.

Safety is of the utmost importance in healthcare. Reporting events that may have negatively impacted the safety of a patient or worker is not only beneficial for future safety, but also serves as a teaching tool.

In James Reason's Swiss cheese model, incidents are thought to be prevented by barriers, however, each barrier has a weakness or hole, similar to a stack of slices of Swiss cheese. Holes in the cheese represent individual errors such as carelessness, neglect, or knowledge deficit. These holes all vary in size and position, just like the holes in slices of Swiss cheese.

Accidents are prevented when errors do not make it through the entire stack of cheese slices. However, if all the holes align, the harm reaches the patient or worker and the system as a whole has failed. This particular model of incident management looks to the entire healthcare system for resolution. Using the Swiss cheese model, accidents are evaluated for organizational impacts, deficits in supervision, prevention of unsafe practices, and unsafe practices themselves.

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So, how do you complete an incident report? In general, each healthcare organization will have a different method of collecting data about an incident. Let's look at what is generally needed when completing an incident report.

Define the accident. This is often a short narrative of what happened.

• Was the patient injured in the process?
• Was it related to a medication?
• Was it related to an equipment failure?
• How long did the incident do undetected?
• Was there a witness?
• Did you assess for injuries?
• Did you assist the patient back to bed?
• Providers should always be notified if the incident directly involved a patient.
• Be sure to note the exact time and date of the incident, or how long it went unnoticed.
• Note the names of people involved, and if there were any witnesses to the incident.

This information is often tracked for trends within an organization, or frequent 'passes through the holes of the Swiss cheese.' If you did not witness a patient fall, document the position you found the patient in, such as "patient found lying on the floor." Include as much detail as possible as this is important especially if the incident requires future legal action.

Remain objective. Avoid assumptions and finger-pointing. Some organizations may request suggestions for preventing the error from happening again be written into the report. Some organizations may choose to evaluate an incident in a digital manner, others may have an in-person meeting with representatives from many disciplines. Being as descriptive as possible helps everyone involved in the review of the incident have a better understanding of the events surrounding an incident.

In the nursing profession, many perceive incident reporting negatively and fear punitive actions. When this is the overwhelming culture within a unit or organization, both errors and near misses often go unreported. Nurses and other healthcare workers may feel that reporting the incident would not actually lead to change in their practice, or that there would be little follow up. It is important for organizations to allow employees to describe their involvement in an incident and discuss what could have been done to prevent the error and how they can resolve any longstanding effects and make resolution with coworkers.

If the incident is to be discussed among a group of individuals, communication should remain nonjudgmental using a teamwork approach. From these discussions, nurses can work together using critical thinking to initiate new processes for their unit or organization that will help prevent any further errors. This can not only benefit patient and workplace safety but also boost morale. By allowing these discussions to take place, the organization works to shift the view that reporting an event is used only for punitive measures, and works to establish an educational outlook from discussing errors.

So what happens if you as a practicing nurse feels that the reported situation was inadequately addressed? Verify your institution's policy, however, in most cases, you work up the chain of command.

Accidents and errors happen. Many healthcare organizations look to Reason's Swiss cheese model to prevent incidents, or to evaluate what may have happened for an incident to occur. Incident reports are records compiled and analyzed by organizations in order to spot trends in errors and incidents as well as assess and evaluate for ways in which such events could be prevented.

When completing an incident report, it is important to remain objective. Note what, where, and who, and the impact the event had on the patient along with the names of providers notified. Be as detailed as necessary and document in a timely manner. These reports may be used if you are called to appear in court related to an event.

It is important for organizations to adopt a culture of safety. Sometimes, errors go unreported by nursing staff as they fear punitive action. Remember that these reports are very important not only in the short term for protecting you and your patients, but also often serve as the basis for new policies and procedures aimed to increase patient and workplace safety.

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