Understanding when and why you need to approach a situation as an incident is sometimes confusing for those minor situations that may seem like they are not worth mentioning. But what exactly constitutes a situation or event where you must file an incident report in the field of nursing?
A minor event may not be significant enough for you to stop what you’re doing and fill out an incident report in a busy ward. That is until it becomes a liability for you and your facility. Here’s the first thing you need to know about the incident 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.
Now that we’ve defined the first of four things you need to know about incident reports in nursing let’s look at the other things you need to know.
Some health care facilities have different standards than others, so we’ll define a baseline standard, and you can use this relative to your facility’s standard of reporting. Even if the standards are different, the concept will remain the same. So, join us in examining the incident report in the field of nursing and four things you need to know.
2. When To Report an Incident Report
There are going to be times when reporting an incident is a no-brainer. For example, a patient slips and fractures their arm. That’s a severe injury from a simple slip, but it happens more times than you might think. What if a patient stubs their toe on an I.V. cart wheel while making their way to the restroom?
Many situations will seem trivial and not worth reporting. And in some cases, nurses fear reprisals from having an incident in their ward. So, sometimes they fear reporting any incidents, albeit trivial ones even though it is in their best interest to report.
How do you define a severe incident worthy of reporting from a minor one? Each facility will likely have its version of these definitions. Indeed no hospital is practicing medicine without a team of lawyers deciding what is or isn’t worthy of note-taking. But, in case your facility’s policies seem a little lax in the explanation department, let’s see if we can lend a hand to your dilemma.
When it comes to liability, we’re not lawyers, and you should always seek your legal advice. However, we know a thing or two about incident reporting. And it seems fitting that an event becomes a reportable incident when it meets one or both prerequisites:
- A person sustains an injury.
- Property sustains damage.
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When A Person Is Injured – File An Incident Report
The simplest way when devoid of a clear and concise plan is the idea of reporting from any injury. It could be as minor as a paper cut in this case. There is no grey area defined, so it’s simple to understand. Any injury requires a report.
With this definite ruling in practice, a medical facility has the best chance of catching potential hazards and correcting them. The potential for an improved standard of care for patients becomes evident when there is no grey area in an incident reporting program.
When Property Is Damaged File An Incident Report
Similar to an incident report in nursing for injuries, you can include a polarized property damage reporting policy in your reporting practices. That is to say; incident reporting happens if damage occurs. The approach is black and white, with no grey area for misinterpretation.
With a reporting strategy of zero tolerance, nothing escapes reporting; minor damages are all reportable. It could be as simple as an I.V. or med cart’s wheel breaking or a broken mirror due to a patient’s outburst. No matter the cause, if the property is damaged, it should fall into the category of required reporting.
3. What To Report
We’ve discussed when to report in the absence of a clear and concise reporting procedure for your medical facility. However, determining what to write is a slightly different topic. Why? Well, we need to clarify what constitutes injury or damage to a person or property. It’s this definition that may have a grey area of its own that can, in some situations, cast doubt upon whether or not to file a report.
Nurses know that sometimes you’re busy – really busy! There are near-miss incidents every minute in a busy ward, just stand and watch a swinging entrance door, and you’ll see multiple safety close-calls. But it doesn’t stop with doors; there are safety concerns around every corner in medical facilities.
And how should one define an injury? A minor paper cut may heal in a day or two, so does it count? If a ward is bustling and the nurses busy, there is a likely chance that nurses may avoid an incident report for minor concerns like paper cuts or stubbed toes.
But what happens when a patient comes back with a lawyer six months later and demands restitution for alleged mistreatment for some very minor paper cut or toe-stubbing incident? If there is no record, you may stand little chance of defense.
The lesson to this dilemma is always to file an incident report if you are notified of an injury, no matter the severity. It’s the only way to ensure that you’ve got a record to fall back on later to protect yourself and the facility you work.
4. Why Nurses Need To File An Incident Report
There are five primary reasons why nurses need to complete incident reports:
- Personal Liability
- Facility/Organization Liability
- Enhanced Patient Care And Facilities
- Improved Workplace Safety Culture
- Improved Restitution Process
Morally, we’re supposed to ignore personal liability and ‘just do what’s right.’ However, in a world where people throw lawsuits like we throw candy to children on Halloween, you’ve got to cover your bases.
No one wants to think that they will be named in a lawsuit, but it happens every day. So, merely for personal liability, nurses ought to complete incident reports with every event that includes property damage (or loss) or injury to anyone.
It doesn’t look right to get fired. No one wants to lose one’s job. Worse yet is to get blackballed in your area due to a facility administration getting sued over something you neglected to report. Not that this is an issue of personal liability (but in a way, it could be).
Keeping your facility out of hot water by maintaining a strict incident reporting regiment is a wise practice.
Enhanced Patient Care And Facilities
Documenting incidents of every type is the only way that safety and operations managers can implement new, evolved, or replacement procedures. From a simple material change to a procedural makeover, without documentation of how an incident came to pass, a facility cannot improve its functions. And we all want a better working environment that strives to improve. In medical facilities, a minor improvement could make the difference between life and death for a patient.
Improved Workplace Safety Culture
In any organization, whether a medical facility like a hospital, a clinic, or another medical establishment, one thing is right – when everyone follows the rules, it’s easy to follow them yourself.
It is valid for incident reporting in the nursing community as well. No one becomes the oddball out when everyone joins in the team effort of improving safety.
Improved Restitution Process
Hospitals are, unfortunately, places that see a lot of incidents. People from every walk of life find their way to hospitals for one reason or another. Sometimes incidents occur like a person’s belongings are stolen. If someone tells a busy nurse of the infraction, but the nurse does not file a report, how will administrative staff know what restitution is deemed fitting given all the facts?
Documenting all incidents within a medical facility is critical for nurses to aid in maintaining safe and fair facilities. The goal should be facilities where patients, visitors, and staff alike get treated with dignity and respect. And that means that they have the right to make claims and find reward in restitution if the situation deems it warranted.
The Final Thought On Incident Reporting For Nurses
The best advice is always to complete an incident report when an injury or damage occurs. A good facility management team will embrace an open policy of reporting and discourage retribution to any nurse who does their duty by completing an incident report.
In any case, the only way to truly protect yourself is to complete a report and complete it factually and without judgment or bias. Completing factually and indiscriminately ensures that you genuinely cover your bases and don’t just create further headaches to deal with in the future.
Frequently Asked Questions
How do you write an incident report in nursing?
Writing an incident report in nursing is similar to writing an incident report in other industries. Following a procedure of steps when writing an incident report ensures uniformity of reporting processes and conformance with facility regulations.
What are the examples of an incident (in nursing)?
Incidents in nursing can range from a wide variety of events and situations. Some examples of incidents in the nursing world are:
- A patient stubs their toe on an I.V. cart.
- A nurse pricks themselves with a needle when they sneeze.
- Someone steals a visitor’s belongings when they are visiting a patient.
- A violent patient outburst injures a nurse.
What makes a good incident report?
A good incident report is a report that includes the vital pieces of information needed to document the incident. There are four things the writer can do to ensure the document is superior:
- Write factually and impartially.
- Never place judgment, blame, or make assumptions in the report.
- Only report facts, not feelings or impressions.
- Record data to the best of your ability quickly and efficiently while maintaining descriptive information gathering.
Now get out there and keep making a difference improving your safety and the safety of those around you. Good reporting and safety come to those who make it happen.
- Featured photo by cottonbro from Pexels