Despite the most careful precaution of medical personnel, medico-legal accidents still occur. In all cases of accidents nurses caring for the client during the time of incident and those who saw or heard the unusual event should write an incident report. The nurse in charge of the department should also write an incident report in cases of accident.
An incident report is a form that filled up in order to record the details of accidents, patient injury and other unusual events that occur in a health care facility such as a hospital or nursing home. It is also called an accident report which documents the exact details of the accident or unusual event while the information is still fresh in the minds of those who witness the event.
Purpose of an Incident Report
People often regard an incident report as a black mark against the nursing staff who wrote it. This should not be the case because an informed consent is a legal document of an incident that took place. The purposes of an incident report are the following:
- To document the exact detail of an accident or unusual incident that occurred in a health-care institution.
- To be used in the future when dealing with liability issues stemming from the incident.
- To protect the nursing staff against unjust accusation.
- To protect and safeguard the client in case of negligence on the part of the nurse.
- Helps in the evaluation of nursing care to ensure safe care to all patients.
- Written at the first opportunity after the incident so that the details are not blurry or forgotten.
- Written with a pen (ink) not pencil. Information written using a pencil can be erased.
- Details should be complete and accurate. The patient should be identified with the following details:
- Full name
- Hospital bed number
- Hospital ID
- Patients diagnosis
- Patient’s condition before and after the incident
Other details included are:
- Details of ward or clinical area
- Date, time and place of incident
- Details of equipments used including the serial number or asset tag identification (if appropriate)
- Written as statement of facts without interpretation or opinion. Descriptive adjectives should not be used.
For example instead of writing:
“Mr. Dimaano would not listen when I told him to stay in bed. He is very difficult to care for. It is his fault why he fell on the floor.”
You should write:
“I heard a loud crash, and immediately went to the ward. I found Mr. Dimaano on the floor.”
- Events should be written in sequence that they occurred.
- Proper technical terms should be used. For example instead of using the word bottle specify that it is a urinal.
- Identifies the witnesses.
- Identifies the medications given before the incident (if applicable)
- Identifies the equipment that is involved or used.
- Signed legibly with the correct designation.