An incident report is a document that describes an accident or incident that deviates from safe nursing standards. Nurses want to exercise utmost care with their work, but accidents do happen and when they do, an incident report needs to be filed. Some incidents requiring incident reports are medication errors, falls, needle stick injuries, damage to equipment, property losses, or any incident which causes harm to the patient because the nurse did not exercise reasonable care.
This report is made to describe the details of an incident, to point out risks, and to contribute to statistical data. It helps to prevent the recurrence of adverse events and to improve patient care. The nurse involved in the situation must fill out an incident form as soon as possible, preferably within 24 hours of the event. The form must be complete, accurate and factual. All pertinent information must be included in the report.
The patient’s full name, initials, and hospital identification number must be written. The nurse also needs to specify the date, time and the place where the incident happened. Only straight facts are to be described in the report. The nurse must be careful not to put blame or draw any conclusions about the incident. Incident reports should be devoid of opinion and bias. The nurse should just describe the incident as it happened.
All witnesses and all those involved in the incident must be identified. Any equipment used during the situation must have its identification code listed as well. The same goes for any drug administered, information about its exact name, form, dosage, and lot numbers or product IDs should be specified.
Any related event or circumstance should also be written. These can put an incident in proper context and will help explain why the incident happened. For example, another patient went into cardiac arrest and took the nurse’s attention away from a patient who fell because she was not immediately assisted.
The nurse should not place or make a copy of the incident report, nor make any reference about the form in the patient’s medical record. Instead, the nurse should make a complete and separate entry regarding the incident in the patient’s chart.
Incident reports are reviewed by nurse supervisors or managers, or sometimes by a panel who will decide on whether to investigate further. The nurse may be required to explain how the incident happened, how it could have been avoided, and what recommendations can be considered. While establishing liability and enforcing punishment of the nurse is not the main goal of the incident report, it can form part of a case of malpractice or negligence against the nurse brought by the patient’s family. In this case, the nurse should seek assistance from the facility or legal counsel.
If an accident occurs, the nurse should assess the client for any injury. Completing the incident report is the next thing to do. Even as this may seem to expose the nurse’s mistake to his or her disadvantage, it is actually designed to protect all those involved: the patient, the nurse, and the facility. Work guidelines on accidents are not meant to establish liability but rather to create precautions so that accidents will be minimized. Safe nursing practice is therefore maintained partly by filing an incident report.