Incident Reporting Process in Healthcare

Amanda Marten, MSN, FNP-C
Incident response plan

You might believe older adults are more likely to fall while in the hospital. Adults 75 years and older account for approximately 29% of reported falls, while around 44% of those 18-64 years experience a fall during a hospital stay, according to the incident reporting process in healthcare data from the Agency for Healthcare Research and Quality (AHRQ).

Incidents, errors, and other issues occur every day in U.S. hospitals. Healthcare organizations are constantly looking for ways to reduce and eliminate problems, and incident reporting is critical for collecting the data that reveals where corrective action is needed most. In this article, I’ll explore how organizations manage the incident reporting process in healthcare.

What Is an Incident Report?

An incident report is a comprehensive documentation of any unintentional or harmful event within a healthcare setting. It contains all pertinent details surrounding the occurrence and subsequent outcomes. Healthcare incidents encompass a broad spectrum of events. Here are four healthcare incident report types:

  • Near-Miss Incidents: Situations where potential harm was narrowly avoided.
  • Non-Patient Related Incidents: Events that don’t directly involve patients but can potentially affect the healthcare environment’s safety, operation, or integrity.
  • No Harm Incidents: Involve errors or deviations from the standard of care that do not harm the patient but indicate a risk potential.
  • Sentinel Incidents: Serious occurrences resulting in severe harm or death.

The Incident Reporting Process In Healthcare

Maintaining compliance with state and federal regulations is paramount for healthcare organizations, and incident reporting plays a pivotal role in this endeavor. Not only is incident reporting required by government agencies such as OSHA, but it also helps to mitigate medical errors and enhances safety standards nationwide.

Here’s a list of the critical stages of the incident reporting process in healthcare:

Initial Response and Disclosure

  • Administer necessary medical aid, contain spills, and notify management if required.
  • Immediately initiate incident reporting procedures when an incident or near-miss occurs.

Preserve Information and Document

  • Accurately and promptly document the incident.
  • Securely shut down equipment, contain hazards, and preserve the scene integrity, if necessary.

Gather Witness Testimony

  • Promptly ask any witnesses to submit an incident report.

Complete the Incident Report Form

  • Using a digital incident reporting solution makes it easy to report incidents from anywhere and attach supporting documents.
  • Utilize the the provided form for the incident type to ensure accuracy and compliance in reporting procedures.
  • Safety managers should promptly conduct interviews after reviewing the incident report to minimize memory distortion and gather additional data when necessary.
  • Safety managers may reassure those involved of non-blameful intent and conduct private discussions to maximize information accuracy.

Report to Authorities

  • Submit required reports to relevant authorities, such as fatalities, employee injuries, hazardous spills, and other mandatory reporting requirements.
  • Consider voluntary reporting to manufacturers, accreditation, and other regulatory organizations.

Determine the Causes

  • Identify and analyze underlying factors contributing to the incident (root-cause analysis).
  • Determine the incident’s root cause, such as human error, equipment malfunction, or a procedural issue.

Implement Corrective Actions

  • Initiate measures to prevent similar incidents from occurring in the future.
  • Tailor corrective action plans to address specific weaknesses identified during the incident investigation.
  • Focus on adherence to safety and quality standards
  • Implement training and protocols as necessary to promote patient and staff safety.

Improve Incident Reporting With Digital Solutions

Incident reporting software simplifies the process while helping healthcare organizations to identify and analyze the possible causes. Digital incident reporting solutions offer accessible-anywhere forms, dynamic form building, anonymous reporting, automated escalation workflows, and severity clarity. Incident report data is also more easily compiled through software, which enables analysis to uncover fundamental reasons behind an incident.

MedTrainer offers comprehensive incident reporting tools tailored to the needs of various healthcare settings, promoting efficiency and compliance. Find out how MedTrainer can enhance your compliance programs with digital incident reporting solutions for organizations of any size. Contact us to learn more.


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