An incident report documents any unintended event that results in harm or has the potential for harm to a patient. It is important to file an incident report for events large and small to facilitate review, corrective actions, and decisions around liability. When writing an incident report, one should objectively describe the facts of the incident without opinions, including all relevant details like those involved, witnesses, location, and immediate responses. Incident reports preserve memory and information in case of future review or legal proceedings.

1. Inquiry Report, Enquiry
Proceedings & Records
Jasmin Anand

2. Introduction
When a situation is significant—resulting in an
injury to a person or damage to property—it’s
obvious that an incident report is required. But
seemingly small incidents also need an incident
report

3. Definition
Patient safety incidents are any unintended or
unexpected incident which could have, or did, lead to
harm for one or more patients receiving healthcare.
Reporting them supports the NHS to learn from mistakes and to take action to keep
patients safe. Aug 30, 2017
Incident reports comprise two aspects.
1.Actual reporting of any particular incident (this may
be something affecting you, your patient or other staff
members)
2.Relevant corrective action taken. ...

4. Hypothetical situations
• You’re helping a post-op patient walk from his bed to the
bathroom, and he stubs the big toe on his right foot on the IV
pole he’s pushing.
• When you check on an elderly patient recovering from a mild
CVA, you find her on the floor, her left arm apparently
fractured. She tells you she was looking for her dog.
• In the process of reconstituting a vial of cefazolin to
administer to a patient with pneumonia, you sneeze as you’re
about to pierce the vial’s stopper to add sterile water, piercing
your thumb with the needle.

5. In which case will you file a report ?
Ans. All three

6. Class to share on hypothetical
situations

7. What Information Do You Write in an Incident
Report?
• Date, time, and facility location.
• Where the incident occurred.
• Incident type.
• Name of the person(s) affected by the incident.
• Witnesses or names and titles of other involved
persons.
• Written summary of what happened, which can
include:

8. When should a nurse complete an incident
report?
The rule of thumb is that any time a patient
makes a complaint, a medication error occurs, a
medical device malfunctions, or anyone—
patient, staff member, or visitor—is injured or
involved in a situation with the potential for
injury, an incident report is required.

9. Why Reports & Records
• Refreshing your Memory
• Triggering a Rapid Response
• Facilitating Decisions about Restitution
• It’s Your Responsibility

10. Reasons why Reporting & Recording is
important
• Refreshing your Memory
You may not be able to rely on memory alone,
but you can count on the incident report to
refresh your memory.
Eg. Feeding my mother is the nurses
responsibility

11. Triggering a Rapid Response
• Administrators, who review it rapidly and act quickly
to change any policy or procedure that appears to
be a key contributing factor to the incident.
• Alert administration that a hospital representative
should talk to a patient or family to offer assistance,
an explanation, or other appropriate support.
• To balm that soothes the initial anger—and
prevents a lawsuit.

12. Facilitating Decisions about Restitution
Provides vital information the facility needs to
decide whether restitution should be made—if
personal belongings were lost or damaged, for
example.
Without proper documentation of the incident,
there’s no way to make these important
decisions effectively.

13. It’s Your Responsibility
You have firsthand knowledge. Failure to do so could
lead to termination. It could also expose you to liability,
especially in cases of patient injury. Protect yourself
and your patients by filing incident reports anytime
unexpected events occur.
If you’re the one who discovers the incident, or you
have been involved in the situation leading up to it and
know more about it than your colleagues, filling out an
incident report is your responsibility. You’re expected to
complete it before the end of the shift during which the
incident occurred or was discovered.

14. Writing Out an Effective Incident Report
• Describe what you saw objectively
• Include the full names
• Add other relevant details – just culture
You Should Keep the Following Points in Mind when
Documenting an Incident:
• Use objective language.
• Write what was witnessed and avoid assigning blame;
write only what you witnessed and do not make
assumptions about what occurred.
• Have the affected person or witnesses tell you what
happened and use direct quotations.

15. When filling out an incident report, include the
following information:
* the exact time and date
* the names of persons involved and any witnesses
* factual information about what happened
• other relevant facts, including your actions (such
as notifying the healthcare provider) and any
corrective actions taken.
• Sign up with Date after completion

16. Describe what you saw
when you arrived on the scene or what you heard that led
you to believe an incident had taken place. Put secondhand
information in quotation marks, whether it comes from a
colleague, visitor, or patient, and clearly identify the source.
Include the full names
of those involved and any witnesses, as well as any
information you have about how, or if, they were affected.
Add other relevant details
Such as your immediate response—calling for help, for
example, and notifying the patient’s physician. Include any
statement a patient makes that may help to clarify his state of
mind, as well as his own contributory negligence.

17. What not to add in your report /what does not belong to a report
Opinions, finger-pointing, and conjecture are not helpful additions to an
incident report.
Do not:
• Offer a prognosis
• Speculate about who or what may have caused the incident
• Draw conclusions or make assumptions about how the event unfolded
• Suggest ways that similar occurrences could be prevented.
• Avoid hearsay and assumptions. If your patient is injured in another
department, it's up to the person who witnessed the incident in that
department to write the incident report.
• Don't assign blame. Refrain from pointing your finger at a coworker or
your facility's administration. An incident report isn't an opportunity
for you to point out inferior equipment or poor staffing. Just state the
facts.
• Forward the report to the person designated by your facility's policy.
Ensure that only one copy of the report exists. If other departments or
committees would like to see the report, the original may be
forwarded to them in succession.

18. All Information in its Proper Place
• If a patient is involved in the event, entering your
observations in the nurses record of the patient’s chart
does not take the place of completing an incident report,
and filling out an incident report is not a substitute for
proper documentation in the medical record.
• Record clinical observations in the chart—not in the
incident report—and make no mention of the incident
report in the patient record. The report is a risk
management or administrative document and not part of
the patient’s record. By including it in a patient’s record,
lawyers may argue that the report is part of the medical
record and should be turned over to the legal team.

19. Incident Reports in Court
• Be honest and factual.
• Fully disclosing what you know early on will
help hospital administrators decide how to
handle any potential legal consequences.
• Preserves your testimony if you’re ever called
upon to appear in court.

20. Enquiry Procedure
• Enquiry officer-Nursing service
• Institutional Lawyer
• Complaint launcher
• Nurse

21. Can an attorney enter incident reports into
evidence?
Whether a patient’s attorney can request and receive a
copy of an incident report as part of the discovery
process and introduce it into evidence in a malpractice
lawsuit is subject to controversy. The law varies from
state to state.
In addition, there are steps facilities can take to avoid
issues, like making the incident report an integral part
of the internal quality assurance process and labeling it
as such.

22. Conclusion: Cover Your Bases. File a Report.
• Filing incident reports that are factually accurate is
the only way to help mitigate potentially disastrous
situations arising from malpractice and other
lawsuits. It’s your responsibility to record unexpected
events that affect patients, colleagues, or your
facility, regardless of your opinion of their
importance.
• If the incident report has been filled out properly
with just the facts, there should be no reason to be
concerned about how it’s used. The danger comes
only when incident reports contain secondhand
information, conjecture, accusations, or proposed
preventive measures that do not belong in these
reports.

23. To File or Not to File: A Few Common Occurrences
A Few Common Occurrences
• A visitor leaves a patient’s room and collides with a housekeeping
trolley left in the middle of the corridor.
• A nursing student observing an ECG tripped over the machine’s
electrical cord and cut her hand as she tried to stop the fall.
• A confused patient took a tube of nitroglycerin ointment from an
unattended medication cart and rubbed it on her leg in an
attempt to ease dry skin.

24. Ponder on These
• What kinds of activities might trigger a disciplinary
action by a licensing board or regulatory agency?
• Should we be seeing preventative procedure patients?
Look at CDC guidelines
• How should I handle documentation in
emergency/disaster situations?

25. FAQs
• The pandemic is resulting in nurses being asked to work in
areas where they don’t have direct experience. Is it true that
we have immunity for potential liabilities during the crisis?
• As an older healthcare provider who may have a higher risk of
contracting Covid-19, what are your recommendations for my
safety
• I currently have a “leave of absence/retirement policy” with
NSO. With the COVID-19 pandemic, I’ve been asked to come
back to work. Do I need to update my policy?
• I currently have a “student policy” with NSO. With the COVID-
19 pandemic, I’ve been asked to come work at a local
hospital. Do I need to update my policy

26. What we need to Know
• OSHA -Occupational Safety and Health
Administration
• INC- Indian Nurses Council
• Nursing Council
• WHO – World Health Organization
• Code of Ethics

27. THE END