Each year in the United States, as many as 440,000 people die from hospital errors including injuries, accidents and infections. Many of those deaths could have been prevented if medical facilities used better documentation of incidents.
Complete, timely patient incident reports provide valuable information for medical facilities. Reviewing incidents helps administrators know what risk factors need to be corrected within their facilities, reducing the chance of similar incidents in the future.
Managing patient incidents can be stressful and time-consuming, especially if your facility has a large number of patients.
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A patient incident report, according to Berxi, is “an electronic or paper document that provides a detailed, written account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting.”
Reports are typically completed by nurses or other licensed personnel. They should then be filed by the healthcare professional who witnessed the incident or by the first staff member who was notified about it.
Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred. You may even want to file the report by the end of your shift to ensure you remember all the incident’s important details.
Patient incident reports communicate information to facility administrators. The information contained in the reports sheds light on measures that need to be taken to provide effective patient care as well as keep your facility running smoothly. These reports help administrators with:
- Risk management. Knowing that an incident has occurred can push administrators to correct factors that contributed to the incident. This reduces the risk of similar incidents in the future.
- Quality control. Medical facilities want to provide the best care and customer service possible. Reviewing incident reports reveals areas that could be improved.
- Training. Using resolved patient incident reports to train new staff helps prepare them for real situations that could occur in the facility. Similarly, current staff can review old reports to learn from their own or others’ mistakes and keep more incidents from occurring.
- Legal evidence. Should a patient take legal action following their incident, a thorough incident report is the most important part of any defense. Thus, all reports should be timely, complete and accurate.
Patient Incident Types
Patient incidents are generally classified into one of three types.
A harmful incident results in injury or illness to a patient or another person. For example, a patient could fall out of bed and break their arm or scratch a nurse as she takes their temperature.
A near miss is when there was potential harm to a patient or another person was almost harmed but the situation was corrected before it occurred. For instance, a patient might get caught trying to leave the facility prematurely or trip but a nurse catches them before they fall.
A no-harm incident means that something happened to a patient or another person but no discernible injury or illness resulted. For example, a patient could be given a blood transfusion meant for another patient but no harm was done because the blood was compatible.
Types of patient incidents that may occur include:
- Patient complaints (e.g. problems with care or care provider)
- Unexpected events related to treatment (e.g. adverse reaction to medication, equipment malfunction)
- Bodily harm (e.g. injury to patient, staff, contractor or visitor)
- Patient-related events (e.g. treatment refusal, leaving against doctor’s orders)
Even if an incident seems minor or didn’t result in any harm, it is still important to document it. Whether a patient has an allergic reaction to a medication or a visitor trips over an electrical cord, these incidents provide insight into how your facility can provide a better, safer environment.
A patient incident report should include the basic information about the incident: the who, what, where, when and how. You should also add recommendations on how to address the problem to reduce the risk of future incidents.
Every facility has different needs, but your incident report form could include:
- Date, time and location of the incident
- Name and address of the facility where the incident occurred
- Names of the patient and any other affected individuals
- Names and roles of witnesses
- Incident type and details, written in a chronological format
- Details and total cost of injury and/or damage
- Name of doctor who was notified
- Suggestions for corrective action
Most importantly, provide as much detail as possible in your patient incident reports. The more information you provide about what caused the incident, the better your chance of stopping similar incidents.
Need help creating your report form? Download our free, editable patient incident report template to ensure your documentation is comprehensive.
According to a study by the US Department of Health and Human Services, 86 per cent of hospital incidents go unreported. Even more staggering, though, is the reason behind this. Staff did not consider 62 per cent of incidents as reportable, due to unclear incident reporting requirements.
Because of this, the first step to incident management in any healthcare facility is writing strong, clear reporting requirements. Then, staff can submit reports that help correct problems of all types.
After the report is filed, the appropriate personnel review it and begin an investigation, if necessary. Following the investigation, they hand the report off to facility administrators with their notes and recommendations. Finally, administrators come up with an action plan to correct underlying issues that caused the incident and confirm that the incident has been resolved.
Tips for Efficient Reporting
In order to record the most accurate account of the incident, maintain an objective tone. Do not include assumptions or assign blame; just write down the facts. Where possible, include direct quotes from the patient and/or other involved parties.
The higher your quality of writing, the more valuable your patient incident report will be. For example, using clear, concise language will make the investigation process faster and easier. In addition, use proper grammar, spelling and punctuation. Grammar mistakes may change the meaning of details within the report, which may make investigating the incident more difficult.
Use Case Management Software
Managing patient incident investigations can be stressful, especially if your facility serves hundreds of patients at any given time. Using case management software, though, streamlines the process so you can improve your facility’s quality of service.
Choose a platform that is web-enabled for quick reporting. You’ll never miss important details of a patient incident because you can file your report right at the scene. A platform with HIPAA-compliant forms built in makes your workflow more efficient and productive, ensuring patient incidents are dealt with properly.
Finally, find a system that is secure. Role-defined access allows only authorized personnel to view sensitive patient data, protecting them as well as your reputation. Learn more about using i-Sight for healthcare facilities here.
Did the patient involved in the incident submit a complaint letter? Use our template to craft a professional, compassionate response.
Twenty-one per cent of American adults have personally experienced a medical error. While this number is astounding, it can be reduced with good incident management practices. Thorough, timely and accurate documentation in your facility’s patient incident reports helps mitigate risk, improving quality of care and your reputation.