What Is a Patient Incident Report?
A patient incident report details the events of a patient’s fall or medical harm. It includes information about patient, doctor, and nurse behavior.
Healthcare incident reporting protects against claims of neglect, harm, or errors. Adding the details of the situation to this report shows proof of the events that led to injury or issues.
Legal Templates provides a customizable patient incident report form. Our template makes it easy to develop helpful and detailed records.
What Is a Patient Safety Incident?
A patient safety incident is an unexpected event that results in a patient’s injury or death. Typically, these apply to events in a hospital, private practice, or care facility. The most common types of patient safety incidents include:
- Sentinel incident: A sentinel incident results in death or extreme harm. It needs immediate evaluation and corrections.
- Near-miss incident: Near-miss incidents don’t result in injury. Usually, no harm occurs because of a quick response.
- No-harm incident: No-harm incidents include events that could have caused harm but didn’t.
How to Write a Patient Incident Report
To write a patient incident report, gather information, witness accounts, and supporting evidence. Use the following steps for healthcare incident reporting:
- Reporter information: State the name and title of the person reporting the event.
- Date and location: Add the exact date, time, and location of the incident.
- Incident type: Select the type that most accurately describes the incident. Also, add relevant details and a description of the event.
- Patient information: Provide the patient’s name and medical reporting number.
- Medical response: Mark whether a healthcare professional performed medical action in response.
- Contextual support: Add witness statements or supporting documents to provide more information.
Incident reports should not go in the patient’s chart. They remain confidential and internal records for healthcare organizations.
Serious Reportable Events & Reporting Requirements
Serious Reportable Events (SREs) are preventable errors that harm patients and require a patient incident report. Cases that qualify as an SRE include:
- Surgical errors: Performing the wrong procedure, operating in the wrong location, or surgery on the wrong patient.
- Drugs or device misuse: Harm from contaminated or improper use of drugs and medical devices.
- Patient release or harm: Serious injuries or death caused by unapproved patient release. This includes patients leaving or harming themselves while not under staff supervision.
- Care management mistakes: Mistakes during treatment, such as dosage or medication errors. This also applies to mishandling samples or not following up with labs.
- Environmental harm: Environmental injuries such as burns, electric shocks, and restraints or bedrails.
- Criminal activity: Report any criminal activity that occurs within a healthcare setting. This includes medical impersonators, abduction, abuse, and assault.
Healthcare incident reporting procedures also include reporting requirements for SRE situations. Depending on the type of event, report the issue to local authorities, medical boards, and regulatory agencies.
Check with state laws and regional medical associations to determine how and when to report medical incidents. Also, consider using a HIPAA business associate agreement to protect confidential patient information when reporting to outside organizations.
Criminal activity also requires a police incident report to alert local authorities.
Patient Incident Report Sample
View our patient incident report sample with the necessary information and formatting. Available to download as a PDF or Word file.
Improve Patient Incident Reporting with Legal Templates
Proper incident reporting procedures include many important parts and considerations. Legal Templates makes developing an effective and thorough report easy. Our tools take you through each step of the reporting process.
An accurate report helps healthcare providers prevent future incidents and improve risk management. Having documentation can also protect against disputes and aid in the development of company policies.
Frequently Asked Questions
How do incident reports improve patient care?
Incident reports improve patient care by identifying ways to improve workplace safety. Checking reports that result in similar incidents can show room for improvement.
Are incident reports shared with the patient?
Incident reports are not shared with the patient, family members, or others. They serve as internal documentation for investigation and record keeping.
Can a patient see their own incident report?
Patients cannot see their own incident reports, even with the use of a medical record release form. These reports remain confidential for the medical facility’s investigations, improvements, and legal protection.
