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?