What Is an Incident Report?

In a health care context, an incident report is a document detailing a series of events that were unusual and resulted in an injury or death in a health care setting. Incident reports also occur in other contexts, such as mandatory reports employees must file for occupational health and safety reasons when they are injured on the job. This article focuses on the use of incident reports in hospitals, clinics, nursing homes, and similar facilities where patients receive medical care or assisted living services.

Protocol at a facility usually requires an incident report when a patient experiences an injury or dies in the care of health care providers for unusual reasons. Thus, a patient dying due to complications from a disease would not merit an incident report, but if a patient falls during a transfer to the operating table, this would necessitate a report to discuss the situation. The goal of the report is to determine what happened, if such situations are preventable in the future, and whether any personnel need reprimands, additional training, or reassignment.

The first step in any incident is to stabilize the patient, get the situation under control, and write orders for additional monitoring of the patient to make sure she fully recovers. Once the situation has been dealt with, hospital personnel can generate an incident report. They collect the information as soon as possible to make sure it is fresh. A coordinator may interview various witnesses and participants, including bystanders who may not work for the facility, to get a complete picture.

This document will describe what happened, using input from personnel who were present and providing detailed information, with a special note about any unusual circumstances, like forgetting to follow safety procedures. It will also discuss the consequences of the incident, such as injuries or deaths. One thing the incident report must do is determine whether injuries were caused by the incident or something else, as the document can be important in discussions of liability. Hospitals must pay for damages they cause, and must also consider the risk of future complications that might require physical therapy or other treatments.

The incident report goes on file at the hospital, usually in the office of a health and safety coordinator. A legal team may subpoena the document if the case becomes subject to litigation, and personnel supervisors can also review it. One potential outcome of an incident report might be a revision to facility policies to prevent future incidents, such as a requirement that two attendants be present at the time of all transfers, to make sure a patient has adequate support.