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Nursing & Patient Incident Reports: A Guide with Best Practices and Examples
Preventable medical errors result in hundreds of thousands of deaths per year. Mitigate risk in your facility by filing thorough, timely patient incident reports.
Each year in the United States, as many as 440,000 people die from hospital errors including injuries, accidents and infections. Many of those deaths could have been prevented if medical facilities used better documentation of incidents.
Complete, timely patient incident reports provide valuable information for medical facilities. Reviewing incidents helps administrators know what risk factors need to be corrected within their facilities, reducing the chance of similar incidents in the future.
Managing patient incidents can be stressful and time-consuming, especially if your facility has a large number of patients.
Learn how case management software can help you resolve incidents faster to improve safety and minimize hazards in our free eBook.
What Is a Nursing & Patient Incident Report in Healthcare?
A patient incident report, according to Berxi, is "an electronic or paper document that provides a detailed, written account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting."
Reports are typically completed by nurses or other licensed personnel. They should then be filed by the healthcare professional who witnessed the incident or by the first staff member who was notified about it.
Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred. You may even want to file the report by the end of your shift to ensure you remember all the incident's important details.
RELATED: Near Miss Reporting: Why It's Important
Why Patient Incident Reporting Matters in Nursing
Patient incident reports communicate information to facility administrators. The information contained in the reports sheds light on measures that need to be taken to provide effective patient care as well as keep your facility running smoothly. These reports help administrators with:
- Risk management. Knowing that an incident has occurred can push administrators to correct factors that contributed to the incident. This reduces the risk of similar incidents in the future.
- Quality control. Medical facilities want to provide the best care and customer service possible. Reviewing incident reports reveals areas that could be improved.
- Training. Using resolved patient incident reports to train new staff helps prepare them for real situations that could occur in the facility. Similarly, current staff can review old reports to learn from their own or others' mistakes and keep more incidents from occurring.
- Legal evidence. Should a patient take legal action following their incident, a thorough incident report is the most important part of any defense. Thus, all reports should be timely, complete and accurate.
Types of Patient Incidents in Hospitals
Patient incidents are generally classified into one of three types.
1. Harmful Incident
A harmful incident results in injury or illness to a patient or another person. For example, a patient could fall out of bed and break their arm or scratch a nurse as she takes their temperature.
2. Near Miss
A near miss is when there was potential harm to a patient or another person was almost harmed but the situation was corrected before it occurred. For instance, a patient might get caught trying to leave the facility prematurely or trip but a nurse catches them before they fall.
3. No-Harm Incident
A no-harm incident means that something happened to a patient or another person but no discernible injury or illness resulted. For example, a patient could be given a blood transfusion meant for another patient but no harm was done because the blood was compatible.
Types of patient incidents that may occur include:
- Patient complaints (e.g. problems with care or care provider)
- Unexpected events related to treatment (e.g. adverse reaction to medication, equipment malfunction)
- Bodily harm (e.g. injury to patient, staff, contractor or visitor)
- Patient-related events (e.g. treatment refusal, leaving against doctor's orders)
Even if an incident seems minor or didn't result in any harm, it is still important to document it. Whether a patient has an allergic reaction to a medication or a visitor trips over an electrical cord, these incidents provide insight into how your facility can provide a better, safer environment.
Step-by-Step Guide to Writing an Incident Report
Accurate and timely incident reporting is critical for ensuring patient safety, promoting transparency, and improving healthcare operations. Here's a step-by-step guide to writing an effective patient incident report:
- Respond to Immediate Needs: Prioritize patient care first. Ensure any immediate medical attention is provided before beginning the report.
- Collect Accurate Information: Gather all relevant details: who was involved, what happened, when and where it occurred, and any immediate outcomes. Use direct observations rather than assumptions.
- Use Clear, Objective Language: Describe the facts in a neutral tone. Avoid language that implies blame or speculation.
- Include Witness Statements: Document any observations from staff, patients, or visitors who witnessed the incident.
- Document Actions Taken: Record any interventions, treatments, or changes implemented in response to the incident.
- Submit the Report Promptly: Complete and submit the incident report as soon as possible—ideally within 24 hours—to ensure accuracy and timely follow-up.
- Maintain Confidentiality: Protect patient privacy by including only the necessary medical and incident details, following HIPAA and institutional guidelines.
RELATED: Preventing Workplace Violence in the Healthcare Industry
What to Include In a Patient Incident Report
A patient incident report should include the basic information about the incident: the who, what, where, when and how. You should also add recommendations on how to address the problem to reduce the risk of future incidents.
Every facility has different needs, but your incident report form could include:
- Date, time and location of the incident
- Name and address of the facility where the incident occurred
- Names of the patient and any other affected individuals
- Names and roles of witnesses
- Incident type and details, written in a chronological format
- Details and total cost of injury and/or damage
- Name of doctor who was notified
- Suggestions for corrective action
Most importantly, provide as much detail as possible in your patient incident reports. The more information you provide about what caused the incident, the better your chance of stopping similar incidents.
Need help creating your report form? Download our free, editable patient incident report template to ensure your documentation is comprehensive.
Patient Incident Management Process
According to a study by the US Department of Health and Human Services, 86 per cent of hospital incidents go unreported. Even more staggering, though, is the reason behind this. Staff did not consider 62 per cent of incidents as reportable, due to unclear incident reporting requirements.
Because of this, the first step to start leveraging your incident management tools in any healthcare facility is writing strong, clear reporting requirements. Then, staff can submit reports that help correct problems of all types.
After the report is filed, the appropriate personnel review it and begin an investigation, if necessary. Following the investigation, they hand the report off to facility administrators with their notes and recommendations. Finally, administrators come up with an action plan to correct underlying issues that caused the incident and confirm that the incident has been resolved.
Tips for Writing Effective Incident Reports
1. Stay Objective and Factual
To record the most accurate account of the incident analysis, maintain an objective tone. Do not include assumptions or assign blame; just write down the facts. Where possible, include direct quotes from the patient and/or other involved parties.
2. Write Clearly and Concisely
The higher your quality of writing, the more valuable your patient incident analysis report will be. For example, using explicit, concise language will make the investigation process faster and easier. In addition, use proper grammar, spelling, and punctuation. Grammar mistakes may change the meaning of details within the patient incident reporting, making investigating the incident more difficult.
3. Use Digital Tools or Case Management Software
Managing patient incident investigations can be stressful, especially if your facility serves hundreds of patients at any given time. Using case management software, though, streamlines the process so you can improve your facility's quality of service.
Choose a platform that is web-enabled for quick reporting. You'll never miss important details of a patient incident because you can file your report right at the scene. A platform with HIPAA-compliant forms built in makes your workflow more efficient and productive, ensuring patient incidents are dealt with properly.
Finally, find a system that is secure. Role-defined access allows only authorized personnel to view sensitive patient data, protecting them as well as your reputation. Learn more about using Case IQ for healthcare facilities here.
Did the patient involved in the incident submit a complaint letter? Use our template to craft a professional, compassionate response.
Twenty-one per cent of American adults have personally experienced a medical error. While this number is astounding, it can be reduced with good incident management practices. Thorough, timely and accurate documentation in your facility's patient incident reports helps mitigate risk, improving quality of care and your reputation.
Follow-Up Actions After Filing an Incident Report
Once a patient incident report is submitted, a thorough and structured follow-up process ensures that root causes are addressed and similar incidents are prevented.
1. Review process
The first step is a formal review by the designated safety or compliance team. They will:
- Validate the accuracy and completeness of the report.
- Interview relevant staff members if needed.
- Review security footage, patient records, or equipment logs associated with the incident.
- Classify the incident based on severity and potential risk.
This review often results in a timeline for further investigation or corrective action.
2. Corrective actions
Based on the findings, corrective actions may include:
- Adjusting clinical processes or protocols.
- Repairing or replacing faulty equipment.
- Revising staffing patterns to reduce risk.
- Implementing environmental modifications, such as additional signage or safety rails.
Corrective actions should be documented, assigned an owner, and tracked for completion to ensure accountability.
3. Communication with affected parties
Transparency is key. Affected parties—including patients, families, and staff—should be informed of:
- The incident (to the extent appropriate).
- Immediate actions taken.
- Planned steps to prevent recurrence.
Communication must be handled with sensitivity and comply with privacy laws. In some cases, risk management or legal teams may assist in delivering updates.
4. Training or updates resulting from incidents
Incident trends often highlight the need for training or process changes. After analysis:
- New training sessions may be introduced to address identified gaps.
- Policy updates may be rolled out and require acknowledgment from staff.
- Refresher courses may be scheduled to reinforce critical safety practices.
Organizations should treat each incident as an opportunity for system-wide learning and improvement.
Example of a Completed Patient Incident Report
Not sure what to include in your report? Use the example below as a guide.
- Date and Time of Incident: April 10, 2025, at 10:30 AM
- Location: Room 204, Surgical Recovery Unit
- Name of Reporting Staff: Jordan Lee, RN
- Patient ID: 1023456
- Type of Incident: Patient Fall
Incident Description:
At approximately 10:30 AM, patient John Doe attempted to walk unassisted from the bed to the bathroom despite a posted fall risk warning. The patient stumbled and fell to the floor. No loss of consciousness occurred. Staff immediately assessed the patient and called the attending physician.
Witnesses:
- Amanda Chen, LPN (witnessed incident)
- Mark Voss, CNA (assisted post-fall care)
Immediate Actions Taken:
- Full assessment completed; minor bruising noted on right hip.
- X-rays ordered and completed; no fractures identified.
- Fall risk education reinforced with patient.
- Bed alarm system reactivated and functionality checked.
Follow-Up Recommendations:
- Review adherence to fall risk protocols.
- Reinforce patient education on fall risks during admission and shift changes.
- Consider additional mobility aids in rooms for high-risk patients.
Confidentiality Statement:
Patient information contained within this report is confidential and has been documented in accordance with HIPAA regulations and hospital policy.
Frequently Asked Questions
1. What should be included in a patient incident report?
A patient incident report should include basic information such as the date, time, and location of the incident, names of individuals involved, details of the incident in chronological order, any injuries or damage incurred, names of witnesses, and recommendations for corrective and preventive action.
2. What is incident reporting system in healthcare?
An incident reporting system in healthcare is a mechanism that allows healthcare professionals to document and report any unexpected events, errors, or incidents that occur within their healthcare facility. This system provides valuable information for facility administrators to identify and address risks, improve quality of care, and ensure patient, staff, and visitor safety.
3. What should not be included in an incident report?
Information that should not be included in an incident report includes assumptions or subjective opinions; it should focus solely on objective facts and details related to the incident.
4. Why are incident reports important in nursing?
Incident reports are really important in nursing because they help keep patients safe. When something unexpected happens—like a patient falling or getting the wrong medication—writing it down in a report helps the hospital figure out what went wrong and how to prevent it from happening again.
It’s not about blaming anyone—it’s about learning from the situation. These reports also make sure the hospital follows safety rules and gives patients the best care possible. Plus, if there are any legal issues later on, the report can be used as a record of what actually happened.
5. How do the 5 W’s help structure an effective hospital incident report?
The 5 W’s—Who, What, Where, When, and Why—are a simple way to make sure your report covers all the important details.
- Who was involved? (Patient, staff, witnesses)
- What happened? (Describe the incident clearly)
- Where did it happen? (Room, department, or location in the hospital)
- When did it happen? (Exact date and time)
- Why might it have happened? (Possible causes or circumstances)
Using the 5 W’s keeps your report organized and easy to understand. It also helps others—like supervisors or safety teams—get a full picture of what occurred so they can take the right next steps.
6. Who is responsible for filing an incident report in nursing?
The person who witnesses the incident or is first told about it is usually the one responsible for writing the report. Most of the time, that’s a nurse, but it could also be another staff member who saw what happened.
It’s important to file the report as soon as possible—ideally before the end of your shift—so the details are fresh in your mind. The goal is to make sure the information is accurate and complete, which helps keep patients and staff safe in the long run.
7. What are common mistakes to avoid in patient incident reporting?
Common mistakes when writing patient incident reports include:
- Waiting too long to write the report, which might cause you to forget important details.
- Using opinions or assumptions instead of facts.
- Missing key details, like the exact time or place of the incident.
- Writing unclearly, using abbreviations or medical terms that others might not understand.
To avoid these mistakes, always write your incident report clearly, quickly, and based only on what actually happened.
8. Do patient incident reports have legal implications?
Yes, patient incident reports can have legal implications. These reports are official records used to document exactly what happened during an incident. If there is ever a legal question or investigation about patient safety, the incident report can serve as proof of what occurred.
Accurate and clear reports protect both the hospital and staff members by showing they followed correct procedures. They also ensure that patient rights are respected and that incidents are handled correctly.
9. How incident reports help hospitals improve safety and policies?
Incident reports help hospitals improve patient safety by providing valuable information on things that go wrong or almost go wrong. Hospitals regularly review these reports to identify patterns or common issues.
This allows them to:
- Change or update procedures to prevent future incidents.
- Provide extra training or resources to staff.
- Adjust hospital policies or rules to make the environment safer for everyone.
Overall, incident reports help hospitals learn from their mistakes and create a safer place for patients and staff.