occurence report should be filled out only if there is an injury to a patient

by Eloy Heller DVM 7 min read

Incident (occurrence) reporting: a cornerstone for safety …

25 hours ago  · Report events of workplace violence (injury and near miss events). Report near miss events for tracking, trending and the opportunity to improve safety/quality before an adverse event reaches a patient, staff member or visitor. Complete an incident report if you are the first person/observer on the scene. Complete the report close to incident time and preferably … >> Go To The Portal


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.

Full Answer

When to write incident reports in hospitals?

Usually, nurses or other hospital staff file the report within 24 to 48 hours after the incident occurred. The outcomes improve by recording incidents while the memories of the event are still fresh. When To Write Incident Reports in Hospitals? When an event results in an injury to a person or damage to property, incident reporting becomes a must.

What happens if the incident report is incomplete?

The incident report is incomplete without the follow-up action details. Each report should include remarks stating what preventive measurements and tactics you have opted to avoid such incidents in the future. Once a final follow-up on the incident report is made, the next phase is reviewing.

Do you know how many hospital incidents go unreported?

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.

Should nurses file incident reports for minor injuries?

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.

When should an occurrence report be completed?

Generally, according to health care guidelines, the report must be filled out as soon as possible following the incident (but after the situation has been stabilized). This way, the details written in the report are as accurate as possible.

Who should complete an occurrence incident report?

Report near miss events for tracking, trending and the opportunity to improve safety/quality before an adverse event reaches a patient, staff member or visitor. Complete an incident report if you are the first person/observer on the scene.

What is an occurrence report in nursing?

1. What Is An Incident Report In Nursing? An incident report in nursing is a report which details an event where a person is injured, or property is damaged. If these conditions occur on medical facility property, completion of an incident report is necessary.

What is occurrence reporting in healthcare?

Occurrence Reporting: Assists in identifying care or safety conditions that may result in an injury to a patient or staff. Assists in monitoring frequency and severity of occurrences, identifying opportunities for quality improvement and/or potential legal liability, and implementing corrective action.

When must an incident report be filled in and who should it be submitted to?

The person involved, or if they are unable to do so, a person on their behalf shall report an incident to their supervisor/manager as soon as possible and submit a report within 48 hours of its occurrence using the online Hazard/Incident Reporting & Investigation System.

What is an occurrence or incident report?

An occurrence report is used to obtain the facts surrounding the incident in a timely manner and to preserve the evidence. When do you fill out an Occurrence Report? Immediately, while the facts are fresh in the minds of the persons. involved. Complete the report by the end of the shift in which the event.

What is occurrence reporting in healthcare facilities and why is it important?

Background. Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care.

Which event would require a nurse to complete and file an incident report?

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.

How do you write an occurrence report?

Every incident report you file should contain a minimum of the following:Type of incident (injury, near miss, property damage, or theft)Address.Date of incident.Time of incident.Name of affected individual.A narrative description of the incident, including the sequence of events and results of the incident.More items...•

What is a patient occurrence?

Any event that is not consistent with the desired operations of the facility or care of the patient. … like an unexpected adverse reaction to medication… • Any “Unusual Occurrence” includes: unexpected outcome or. unexpected need for intervention. … like an unexpected slip/fall by a patient or visitor…

What is mandatory occurrence reporting?

Mandatory occurrence reporting will legally require specific people responsible for the safety of these buildings to capture and report certain fire and structural safety issues ('safety occurrences') to the Building Safety Regulator.

What should be documented in an incident report?

8 Items to Include in Incident ReportsThe time and date the incident occurred. ... Where the incident occurred. ... A concise but complete description of the incident. ... A description of the damages that resulted. ... The names and contact information of all involved parties and witnesses. ... Pictures of the area and any property damage.More items...•

Why is it important to review patient incidents?

Reviewing incidents helps administrators know what risk factors need to be corrected within their facilities , reducing the chance of similar incidents in the future.

Why is it important to know that an incident has occurred?

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.

Why 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.

Why do we use resolved patient incident reports?

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.

What to include in an incident report?

Every facility has different needs, but your incident report form could include: 1 Date, time and location of the incident 2 Name and address of the facility where the incident occurred 3 Names of the patient and any other affected individuals 4 Names and roles of witnesses 5 Incident type and details, written in a chronological format 6 Details and total cost of injury and/or damage 7 Name of doctor who was notified 8 Suggestions for corrective action

How long does it take to file a patient incident report?

Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred.

Why is it important to document an incident?

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.

How to write an incident report?

In determining what to include in an incident report and which details can be omitted, concentrate on the facts.#N#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.# N#Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected .#N#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.#N#It’s equally important to know what does not belong in an incident report.#N#Opinions, finger-pointing, and conjecture are not helpful additions to an incident report.#N#Do not:

Why is incident reporting important?

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.

Why is it important to file incident reports?

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.

What is the duty of a nurse?

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.

What happens when incident reports are filled out properly?

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.

Why is it important to talk to a hospital representative?

That’s an important function because such communication can be the balm that soothes the initial anger —and prevents a lawsuit.

What is not a good addition to an incident report?

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.

What is priority in nursing?

The priority is the patient at the time of an error, adverse event, occurrence or variance that leads to harm and/or potential harm.

What is the role of a nurse in assessing a client?

Whenever an error, event or irregular occurrence occurs, the nurse must immediately assess the client and their responses to it and provide the care that is indicated by the client's condition. For example, the client will be assessed for their neurological status and level of consciousness after a fall when it is possible that the client hit their head on the floor as a result of the fall.

What is the purpose of reporting health care incidents?

The purpose of this reporting is to give the health care facility and the health care professionals the opportunity to address the issue and prevent the occurrence ...

What is a written report for incidents?

Generally speaking, all incidents, accidents, adverse events, irregular occurrence and variances require the completion of a written report that will be sent to the risk management and/or performance improvement department as per the specific facility's established policies and procedures. Simply stated, incidents, accidents and events ...

What are incidents that must be documented?

Simply stated, incidents, accidents and events that must be reported and documented include occurrences that are not expected, not normal, irregular and potentially or actually harmful to the patient, staff, visitors and others. Variances, or deviations from practice, that lead to a quality defect or problem are reported.

What is the information that is typically reported on a formal incident or accident report?

Information that is typically reported on a formal incident or accident report includes: The date, time and place of the incident or accident. Clear, concise and objective data about the occurrence and any surrounding factors, like a wet floor, that may have led to the incident or accident.

What is an incident in healthcare?

An incident is an unfavourable event that affects patient or staff safety. The typical healthcare incidents are related to physical injuries, medical errors, equipment failure, administration, patient care, or others. In short, anything that endangers a patient’s or staff’s safety is called an incident in the medical system.

Why is incident reporting important?

Improving patient safety is the ultimate goal of incident reporting. From enhancing safety standards to reducing medical errors, incident reporting helps create a sustainable environment for your patients. Eventually, when your hospital offers high-quality patient care, it will build a brand of goodwill.

Why is reporting important in healthcare?

Reporting can also make healthcare operations more economically effective. By gathering and analyzing incident data daily, hospitals’ can keep themselves out of legal troubles. A comprehensive medical error study compared 17 Southeastern Asian countries’ medical and examined how poor reporting increases the financial burden on healthcare facilities.

What is clinical risk management?

Clinical risk management, a subset of healthcare risk management, uses incident reports as essential data points. Risk management aims to ensure the hospital administrators know their institution performance and identify addressable issues that increase their exposure.

What are near miss incidents?

#2 Near Miss Incidents 1 A nurse notices the bedrail is not up when the patient is asleep and fixes it 2 A checklist call caught an incorrect medicine dispensation before administration. 3 A patient attempts to leave the facility before discharge, but the security guard stopped him and brought him back to the ward.

How much of healthcare is wasted?

Even the World Health Organisation (WHO) has estimated that 20-40% of global healthcare spending goes waste due to poor quality of care. This poor healthcare quality leads to the death of more than 138 million patients every year. Patient safety in hospitals is in danger due to human errors and unsafe procedures.

How long does it take to file an incident report?

Usually, nurses or other hospital staff file the report within 24 to 48 hours after the incident occurred. The outcomes improve by recording incidents while the memories of the event are still fresh.

Is an incident report considered an internal investigation?

Your incident report is considered an internal investigation document. You should never document in your nurses notes that an incident report was completed. If you do, your report may be used in court. They are only to be used internally to investigate the incident.

Can an incident report be brought in as evidence?

The incident report cannot be brought in as evidence unless it's noted in the chart. So no note...no incident report. I know to me it sounds kind of crappy because it seems to protect the hospital and could cause "harm" to the pt if there is a suit...but policy is policy. This policy may cover my butt sometime.