How to Write a Nurse Incident Report
Incident Report in Nursing
Many nurses fear incident reporting in healthcare. They cringe at the notion of wasting time on paperwork, and they are anxious about the potential negative effects on their job prospects. The fear of reporting stems from misunderstandings around the purpose of the practice and the lack of knowledge on efficient reporting techniques. Today, we'll resolve both issues for you and share expert tips on writing detailed and useful reports.
What Is an Incident Report?
A medical incident report is nothing more than a written or electronic record of an unexpected occurrence you've witnessed or were alerted about. It's part of a hospital routine, as no one is completely safe from making mistakes. Ideally, you need to complete the report within 24 hours of an incident to make it detailed and accurate.
What is a Patient Incident Report
According to Berxi, a Patient Incident Report 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. That records the details of an incident or near miss that occurred during the care of a patient. It is used to document the events, actions taken, and any outcome that resulted from an incident. The report is intended to help identify any areas of improvement in the care provided and to prevent similar incidents from happening in the future.
What Is the Purpose of Incident Report in Nursing?
Reporting serves many purposes, but the core ones include:
- Risk management
- Quality assurance
- Personnel training
- Legal liability mitigation
Risk management is listed as the principal purpose of incident report in nursing because our main goal is always keeping patients safe from harm. And addressing systematic risks, such as medical mistakes during night shifts, is supposed to protect the patients.
Analyzing reports can identify the aspects of nursing care in need of improvement to ensure all clients receive cost-effective and high-quality care. Repeating issues within the incident reports should be addressed first to improve patient satisfaction.
Incident reports are an invaluable training tool, as nurses get a chance to learn from their own mistakes and those of others. Studying reports is especially important for nursing students and entry-level nurses.
In the worst-case scenarios, incident reports can be used in court to protect the hospital administration and staff from medical negligence and medical mistake charges. For this reason, reports should be accurate and detailed.
Four Types of Incident Reporting in Healthcare
What Classifies as an 'Incident'?
Most hospitals have guidelines listing situations requiring a patient incident report. Consult hospital guidelines for specifics, but the consensus is that you should report anything unexpected happening that has the potential to harm or damage the patient, medical staff, or facility infrastructure.
Clinical Incidents
Clinical incidents are the most common among different types of incident reports in healthcare. They are also the most dangerous for the patient. You file these reports whenever a mistake occurs in patient care. If you've accidentally administered the wrong medication dose or seen someone stick a needle, you need to file a clinical incident report.
Near-miss Incidents
Unlike the previous category, these incidents do not result in any harm to the patient. Instead, they describe a situation where a potential mistake could have occurred but was instead avoided. You file near-miss paperwork to bring attention to potential issues that should be resolved before actual mistakes have a chance to occur.
Non-clinical Incidents
When unexpected and harmful situations occur outside the nursing care practice, non-clinical reports are filed. In most cases, a patient will suffer damage while being alone and report the harm incurred to you. For instance, if they fall off the bed when trying to get up, that's a non-clinical incident you need to report.
Workplace Incidents
Any issues within the medical personnel community that have the potential to harm the patients should also be reported. For instance, if the nurses have to work overtime because of staff shortage, the risk of mistakes increases, and the report should be filed to draw the administration's attention to staffing problems.
What To Report: Components of Incident Report
A detailed nursing incident report follows the formula 4W + H. It answers the questions of who, what, when, where, and how regarding the incident, explaining what happened in chronological order and including all pertinent information:
- Date and time of the incident
- The location of the incident
- Type of incident
- Full names of people involved in the incident
- The full names the titles of incident witnesses and involved third parties
- A chronological description of what happened
- The accounts by the subject of the incident and its witnesses
- Injuries and damages incurred in the incident
- Immediate response to the incident
- Administered treatments, measures taken to address damages
- Factors contributing to the incident
- The names of staff notified of the incident
- Recommendations for preventing future incident reoccurrence
Tips for Writing an Effective Incident Report
File Reports ASAP
Most hospitals require you to file a report within 24 hours of an incident occured while your memories are still fresh. Start composing your report as soon as all necessary measures are taken to ensure the safety of everyone involved in the incident. Jot down as many pertinent details as possible if you don't have a chance to file the report immediately.
Be Objective
Reporting is about preventing future mistakes, not finding scapegoats. So don't try to cast blame or make assumptions about the cause of the incidents if you have no first-hand knowledge. Keep judgment out of your reports, and simply state what you saw or heard to the best of your ability.
Use Direct Quotes
If you deem patient or colleague statements necessary parts of your report, use direct quotes without paraphrasing. Include their titles and full names when quoting anyone in your report. You can go as far as recording their statements to transcribe for your report later.
Make It Presentable
Just because it's short and sometimes painful to write, a hospital incident report is still a legal document. It should follow the standard grammar and punctuation rules and be free of indecipherable acronyms, nursing jargon, etc. Remember, your report can be used in court, and it's in your best interest to make it as clear and complete an incident report as precise as possible.
Examples of Incidents Reports In Healthcare
12/03/2021, 10:30 Patient John Doe walked down the hall from his room for an X-ray accompanied by Nurse Kalie Richards. The patient was not using the cane, slipped on the wet floor, and fell. The nurse helped him get up and led him back to his room for a visual assessment. No injuries were found, and the patient reported no pain. Nurse Richards used the wheelchair to take the patient for an X-ray and reported the incident to Charge Nurse Monica Williams.
01/08/2022, 12:00 Nursing student Kate Johnson observed an EKG along with her group when she tripped over an electric cable of the machine and cut her hand on the sharp edge when trying to break her fall. The machine did not suffer any damage, but patient Sam Wilks was disturbed, and the results of the EKG were discarded. The procedure was postponed for 30 minutes. Nurse Nancy Berenson took Johnson to the nurse station and administered first aid. The cut did not require stitches but had to be covered with a bandage. Better cable management in the EKG room and better student in machine handling training are necessary to prevent repeat incidents.
02/27/2022, 05:30 Patient Carolina Vasquez took a tube of nitroglycerin ointment from a medication cart left unattended in the hall. She was confused and rubbed the ointment over her hands to ease the sensation of dry skin. Charge Nurse Mary Leeman witnessed the incident and took the patient to her room, cleaned off the ointment, and provided a cream to soothe the sensation and a mild sedative to help the patient sleep. The patient did not have any complaints and reported feeling better after administering the cream. The cart had been left unattended by orderly Nick Brewer, who responded to a commotion inside one of the patient rooms and left the cart in the hall. Charge Nurse Leeman reminded him of the proper procedure and instructed him to bring the medication cart to the nurse station if there was ever a need to leave it.
Benefits of Hospital Incident Reporting
From a personal perspective, incident report nursing practice helps you grow as a professional. By writing, reading, and analyzing incident reports, you learn to troubleshoot, prevent repeating issues, and take better care of your patients. As a result, you gain valuable skills and experience that should see you move up the career ladder.
From an institutional perspective, reporting keeps medical staff accountable and makes the space safer for personnel, medical students, and patients alike. Timely addressing incident reports is also a chance to prevent legal issues down the road, as it prevents medical mistakes and negligence.
From the patient's perspective, a hospital that files and addresses incident reports is a safe and comfortable environment conducive to improving existing health conditions and preventing unfortunate accidents. Medical facilities with robust incident reporting systems pose a lower risk of additional injury and medical mistakes.
Healthcare Incident Reporting Challenges and Drawbacks
Aside from the negative connotations associated with writing a nurse incident report, reporting disrupts your workflow. Instead of taking a break or caring for your patients, you need to set aside at least 30 minutes to organize everything you know about the incident and put it on paper. Thus every incident creates extra work for you, and ignoring reporting becomes a major temptation despite the potential administrative repercussions.
Besides, despite college professors' best efforts at teaching us writing, very few people are good at putting their thoughts and ideas on paper. Even if all you have to do is recount the incident, it may become a hurdle if your writing skills aren't the best. And filing a messy report is likely to raise questions and potentially put your competency under question.
Finally, reporting workplace incidents may cause friction within the nursing staff. Some colleagues may equate your report to “telling on them”, even if they did nothing wrong. Frequent reports could lead to an unhealthy and hostile working environment that's potentially harmful to nurses and patients alike.
Conclusion
Luckily, you don't have to struggle with incident reports on your own. Our nursing paper writing service has an excellent team of experienced nursing writers who can take over for you. As soon as you provide incident details, we'll get one of our pros on your case and deliver a flawless report within 24 hours, ready for you to file. Reach out to our support team, and they'll answer all your questions and help you get your incident report on time.