Who, What, How, and Where are all questions that should be answered when reporting and following up on an incident.
Who? – The employee/staff or volunteer person who discovers, witnesses, or to whom the event is reported should be responsible for documenting the incident. It is important that incident reporting be non-punitive process.
What? – Be objective. Report only FACTS. Do not report conclusions, opinions, accusations or admissions of wrong-doing. Never place blame or point your finger. The following details are some important items that should be included in the report:
- Time, date, and location of the incident
- What happened and what effect it had on the individual(s) involved. Example: “Patient found on floor, right hip injured.”
- Medically relevant facts as well as environmental details relevant to the event.
Example: “Side rails up, bed in low position” “Patient alert and oriented to time and place”
- Statement of the patient or witnesses regarding degree of injury and what happened.
Example: “I saw him stumble when he slid off the foot of the bed” “My right hip hurts”
- Injuries as observed by medical personnel.
Example: “Right foot is rotated” “Reddened area noted on right hip”
- Information that indicates final outcome.
Example: Results of lab work, x-rays, etc.
How? – The Incident report form allows information to be recorded and preserved for quality and risk management purposes. The form should be sent through pre-determined channels to the appropriate administrative personnel. Never make copies of an incident report form. Remember the report is a confidential document.
It should not be made part of the patient record.
- Documentation – The fact that an incident report has been completed should not be documented in the patient record; however, those events which have a direct medical effect on a patient should be recorded in their record. The chart should be complete and accurate, reflecting the patient’s response to the event for at least the next 24- 48 hours.
Where? – The appropriate channels for communication should be specified by an organization’s policies. Most often those persons who need to be informed of an incident include:
- The Patient’s Attending Physician – needs to know what happened to determine the effect of the event on the patient and to take appropriate action. The time and date of physician notification should be documented.
- The Immediate Patient Care Supervisor – needs to know what has happened in order to take action to prevent a recurrence.
- The Risk Manager or Quality Improvement Coordinator—of an organization will use the information from incident reports to institute corrective action and to develop staff education as a long-range benefit. The information should also be tabulated to determine statistical trending and identify high frequency and high severity exposure areas.
- Family/Guardian of Patient —needs to be notified of the incident and the follow-up plan of action.
- Other Specified Personnel —the Medical Director, Pharmacist, or Safety Officer may be involved in the review of specific types of incidents.