Incident Reports

An incident is an event that does not normally occur within the regular health care facility routine and may involve patients, visitors, physicians, hospital staff, or students. The incident may be the result of an accident, such as a patient’s falling while on the way to the bathroom, or it may involve a situation such as spilled liquids in a hospital corridor that cause someone to slip and sustain an injury. Events other than accidents that occur within the hospital or on hospital property are also reportable.

Incidents that require written reports include the following:

When an incident or event occurs, the health unit coordinator (HUC) prepares an incident report form for the person who is reporting the incident or event. Many facilities use computer programs by which incident or event reports are generated electronically.

An incident report form (Fig. 21-1) should be completed for all incidents that occur to anyone, no matter how insignificant they may seem. Documentation of all incidents is important in identifying hazards and preventing continuing problems, and in the case of a lawsuit that may arise from them. The names and home addresses of witnesses are required in case the incident should result in a lawsuit and the witnesses are no longer employed at the hospital when the case is brought to court.

The attending doctor, hospitalist, or resident may be called to examine the patient involved in an incident. All incidents involving patients are reported to the attending doctor. Copies of the incident report are sent to the nurse manager, to risk management, and to quality assurance. If the incident involves another department, a copy is sent to the manager of that department. The incident report never becomes a part of the patient’s permanent record.

Employee hospital incidents must be documented and the employee seen by the employee health nurse or evaluated by a doctor to be eligible for coverage by the state Workers’ Compensation Commission. Hospital employees who fail to put into writing something that may appear trivial, such as a finger puncture with a needle, have no evidence to present should an infection develop after the injury. Exposure to blood and body fluids as may be caused by a needle stick may require the employee to be tested for human immunodeficiency virus (HIV) if the patient who is involved has not been tested.

Risk management personnel may interview witnesses to a patient incident in preparation for a lawsuit. Risk management staff also study patient incidents to look for trends and to prevent future similar incidents.

The HUC is responsible for maintaining a supply of incident report forms for the nursing unit.

Infection Control

For statistical purposes, records of infectious diseases must be maintained. A report should be submitted to the infectious disease department or to personnel in the hospital (Fig. 21-2). Most hospitals employ an epidemiologist or an infection control officer who maintains all infection records and investigates all hospital-acquired infections. Infection control is essential for providing a safe environment for patients and health care workers. Patients are at risk for acquiring infection because of lowered resistance to infectious microorganisms and increased exposure to numbers and types of disease-causing microorganisms, and because they must often undergo invasive procedures. The presence of a pathogen does not mean that an infection will begin. Development of an infection depends on six components called the chain of infection, as follows (Fig. 21-3):

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