INTRODUCTION

The report is an oral, written or computer-based communication intended to to convey information

to others. These can be formal or informal. Reporting is the process of informing the other staff
about the patients and of other events. It is summary or a statement of information that presents
facts regarding planning, coordinating, performing, and the general state of services in an
organization.

In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or
accident report is a form that is filled out in order to record details of an unusual event that occurs at
the facility, such as an injury to a patient. The purpose of the incident report is to document the
exact details of the occurrence while they are fresh in the minds of those who witnessed the event.
This information may be useful in the future when dealing with liability issues stemming from the
incident.

Definition:

1. Incident:

It is an unplanned event within the scope of this procedure that causes, or has the potential to cause,
an injury or illness and damage to equipment, buildings, plant or the natural environment.

2. Incident reports or occurrence reports:

These are the reports indicating unusual incidence regarding patient care such as medication errors
or accidents such as falls. Incident reports can help in improving the treatment of patients. The
reports should be concise and accurate. Do not explain the cause or make excuses and don't place
blame in the report.

TYPES OF INCIDENT

There are mainly three types of incidents

Near Miss

➤ Adverse Events

Sentinal Events

Near miss:

This is where the incident did not result in harm, loss or damage, but could have, this is referred to as
a 'Near Miss'. This may be clinical or non-clinical. Near miss reporting is just as important

in highlighting weaknesses in systems, policies/procedures and practices. If near misses are reported
and learnt from and any necessary corrective action taken, they can help to prevent actual incidents
of harm loss or damage from occurring. Near miss should be reported with in 24hrs of working days.

Adverse events:

Adverse Incident (Clinical) An event or circumstance arising during clinical care of a patient that could
have or did lead to unintended or unexpected harm". Adverse Incident (Non-Clinical) An event or
circumstance that could have or did cause unexpected or unwanted harm, loss or damage to any
individual(s) involved (including patients but not related to clinical care, staff, visitors etc) or damage
to/loss of property/ premises in the hospital. It should be reported with in 2 hrs.
Sentinal events:

An unexpected incident, related to system or process deficiencies, which leads to death or major and
enduring loss of function for a recipient of healthcare services. It should be reported immediately.

Incident reporting (staff)

It is a requirement of all Hospital staff that they report any incident, accident or potential incident
which has caused or has the potential to cause harm, loss or damage to any individual involved or
loss or damage in respect of property premises for which the hospital is responsible.

HOW TO REPORT AN INCIDENT

1. Obtain the proper forms from your institution:

Each institution has a different protocol in place for dealing with an incident and filing a report.

2. Start the report as soon as possible:

Write it the same day as the incident, if possible, because if you wait a day or two your memory will
start to get a little fuzzy. You should write down the basic facts you need to remember as soon as the
incident occurs, and do your report write-up within the first 24 hours afterward.

3. Provide the basic facts:

Your form may have blanks for you to fill out with information about the incident. If not, start the
report with a sentence clearly stating the following basic information given in the Incidence form.

4. Write a first person narrative telling what happened:

For the meat of your report, write a detailed, chronological narrative of exactly what happened when
you report to the scene. Use the full names of each person who is included in the report, and start a
new paragraph to describe each person's actions separately.

5. Be thorough. Write as much as you can remember -

The more details, the better. Don't leave room for people reading the report to interpret something
the wrong way. Don't worry about your report being too long or wordy. The important thing is to
report a complete picture of what occurred.

6. Be accurate:

Do not write something in the report that you aren't sure actually happened.

7. Be clear. Don't use flowery, confusing language to describe what occurred:

Your writing should be clear and concise. Use short, to-the-point, fact-oriented sentences that don't
leave room for interpretation.

8. Be honest:

Even if you're not proud of how you handled the situation, it's imperative that you write an honest
account. If you write something untrue it may end up surfacing later, putting your job in jeopardy and
causing problems for the people involved in the incident.

9. Submit your incident report:

Find out the name of the person or department to whom your report must be sent. When possible,
submit an incident report in person and make yourself available to answer further questions or
patient clarification

PERSON RESPONSIBLE FOR THE IMMEDIATE MANAGEMENT OF THE INCIDENT

The person responsible for the immediate management of the incident (e.g. the nurse in charge of
the ward at the time an incident occurs), should undertake an immediate assessment of the
situation, in order to determine any immediate treatment and/or ongoing care needs of the affected
person, and/or the extent of any loss/damage to property and any other immediate action required
(c.g. removal and isolation of faulty equipment). The situation/scene should be made safe.

ROOT CAUSE ANALYSIS

Root Cause Analysis' is a structured investigation process that aims to assist in the identification or
the root or underlying cause(s) of a particular event or problem by determining WHY the failure
occurred and the actions necessary to prevent or minimize the risk of recurrence. A 'Root Cause' is a
failure in a process that, if eliminated, would prevent an adverse incident occurring. Training for the
relevant staff on incident grading/investigation and root cause analysis will be provided as part of the
risk management training programme.

FAIR BLAME CULTURE

In an organization as large and complex as the Hospital, things will sometimes go wrong. The wrong
assessment should not be one of blame and retribution, but of learning, a drive to reduce risk for
future patients and staff. Blame cannot, and should not, be attributed to individual health care
professionals. Identifying and addressing dysfunctional systems is, therefore, the key to reduce the
risk of harm for many patients and staff through incident form.
INCIDENT REPORT OF AIIMS BHUBANESWAR
CASUALTY
 COLLEGE OF NURSING
AIIMS BBSR
SUBJECT: NURSING MANAGEMENT
DOCUMENTATION OF VARIOUS
REPORTS

SUBMITTED TO SUBMITTED BY:

DR GOMTHI B TANIA MISHRA

ASSISTANT PROFESSOR MSC NURSING 2ND YEAR

COLLEGE OF NURSING ROLL NO.- 24

AIIMS BBSR COLLEGE OF NURSING