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Incident reporting is an accountability of all staff working in healthcare facilities.
Knowing how to fill out an incident report is necessary knowledge for any professional. An incident report should be completed immediately after an incident has occurred and appropriate corrective action followed.
Incident reports are integral to a functional healthcare system that is committed to ongoing improvement and transparency.
The following is intended as a general guide to filling out an incident report. Your organisation may have certain criteria involved in completing an incident report and it is advised that you make yourself aware of the appropriate policies specific to your facility.
Incident reporting relates to Standard 5: Organisation’s Service Environment and Standard 6: Feedback and Complaints of the Aged Care Quality Standards. It also relates to Standard 1.11 of The National Safety and Quality Health Service (NSQHS) Standards.What is a Reportable Incident?
A reportable incident is anything that happens out of the ordinary in a facility. Specifically, unplanned events or situations that result in, or have the potential to result in injury, ill health, damage or loss (Benalla Health 2011).Examples of a reportable incident:
- An aged care resident slips and falls on their way to the bathroom.
- A resident is accidentally dispensed a medication prescribed for another resident.
A clinical incident is defined by the Australian Commission on Safety and Quality in Healthcare as “an event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a person and/or a complaint, loss or damage” (ACSQHC 2017).
(My Health Record 2019)
Clinical incidents could involve:
- Falls and other injuries;
- Medication errors;
- Pressure ulcers;
- Treatment issues;
(Benalla Health 2011; Ausmed 2016)Non-clinical Incidents
- Hazard(s) identified;
- Injury to staff members;
- Injury to students or visitors;
- Professional misconduct;
- Property issues;
- Security issues or breaches;
- Vehicle accidents;
(Benalla Health 2011; Ausmed 2016)
Take into consideration the above as well as other issues as outlined by your organisation.Immediate Actions to Take Following an Incident
Before documenting information regarding the care provided prior to and following the incident in a medical record, ensure that the affected person(s) in the aftermath of the incident is safe and that all necessary steps have been taken to support and treat them.
Ensure preventative measures are in place in anticipation of further injury. Inform a line manager and, if appropriate, preserve evidence in the surrounding area (SA Health 2019).How to Write An Incident Report
An incident report requires questions relevant to who, what, when, where, how and why to be completed (Department of Health Victoria 2011; Ausmed 2016).
- The name of the person reporting the incident.
- The name of the person(s) affected.
- The names of any witnesses.
- What occurred (incident type).
- Characteristics of the incident (injuries?)
- What initial actions did you take?
- Incident severity rating.
- When did the accident occur?
- Where did the accident occur?
How and why
- How and why did the incident occur?
- What were the contributing factors (i.e events surrounding the incident)?
(Department of Health Victoria 2011; Ausmed 2016)Considerations for Completing a Report
- Use concise, objective language (void of emotion);
- Be as specific as possible;
- Write what was witnessed and avoid assigning blame;
- Write only what you witnessed and avoid making assumptions about what occurred;
- Have the affected person or witnesses tell you what happened and use direct quotations;
- Ensure that the person who witnessed the event writes the report; Avoid abbreviations;
- Report the incident in a timely manner.
(Ausmed 2016; SA Health 2011)Who can complete an incident report?
Incidents can be reported by staff, visitors, community members, students, contractors, patients/clients/residents, and volunteers (Benalla Health 2011).Is there a broader purpose for an incident report?
An incident report not only has the potential to shed light on a particular incident, but may reveal room for improvement in systems, procedures, and environments.
In addition, an incident report:
- Recognises that patient and resident incidents often have contributing factors that are, for the most part, related to the systems of care, as opposed to the individual;
- May involve the reporting and management of an entire clinical team, leading to timely action and reduced risk;
- Puts the focus on quality improvement, creating a just and transparent culture, which includes support for the staff involved in the incident.
(SA Health 2019)Additional Resources
- Aged Care Quality Standards: https://agedcare.health.gov.au/quality/aged-care-quality-standards
- Best Practice Guide to Clinical Incident Management | Queensland Health: https://clinicalexcellence.qld.gov.au/sites/default/files/2018-01/clinicalincidentguide.pdf
- National Safety and Quality Health Service Standards (second edition): https://www.safetyandquality.gov.au/sites/default/files/2019-04/National-Safety-and-Quality-Health-Service-Standards -second-edition.pdf
- Australian Commission on Safety and Quality in Healthcare 2017, National Safety and Quality Health Service Standards, viewed 28 August 2019, https://www.safetyandquality.gov.au/sites/default/files/migrated/NSQHS-Standards-Sept-2012.pdf
- Benalla Health 2011, Incident Reporting Procedure, Benalla Health, viewed 28 August 2019, https://www.benallahealth.org.au/userfiles/files/VHIMSIncidentReportProcedure.p df
- Editorial Team, A. 2016, 'How to Write an Incident Report', Ausmed, viewed 28 August 2019, https://www.ausmed.com/cpd/articles/how-to-write-an-incident-report
- My Health Record 2019, Report a Clinical Incident or Issue, Australian Digital Health Agency, viewed 28 August 2019, https://www.myhealthrecord.gov.au/for-healthcare-professionals/howtos/report-cli nical-incident-or-issue
- SA Health, Reporting Patient Incidents, Government of South Australia, viewed 28 August 2019, https://www.sahealth.sa.gov.au
Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile