INCIDENT REPORTING IN HOSPITAL

2. PRESENTATION ON
INCIDENT REPORTING
BY
VIDYA

3. INTRODUCTION
Incident: It is an unplanned event within the scope of this
procedure that causes, or has the potential to cause, an injury or
illness and damage to equipment, buildings, plant or the natural
environment.
● In a health care facility, such as a hospital, nursing home, or
assisted living, an incident report or accident report is a
form that is filled out in order to record details of an unusual
event that occurs at the facility, such as an injury to a
patient. The purpose of the incident report is to document
the exact details of the occurrence while they are fresh in the
minds of those who witnessed the event. This information
may be useful in the future when dealing with liability
issues stemming from the incident.

4. TYPES OF INCIDENT
● There are mainly three types of incidents
● Near Miss
● Adverse Events
● Sentinal Events

5. NEAR MISS
This is where the incident did not result in harm, loss
or damage, but could have, this is referred to as a
‘Near Miss’. This may be clinical or non-clinical.
Near miss reporting is just as important in highlighting
weaknesses in systems, policies/procedures and
practices. If near misses are reported and learnt from
and any necessary corrective action taken, they can
help to prevent actual incidents of harm,loss or damage
from occurring.
Near miss should be reported with in 24hrs of
working days.

6. ADVERSE EVENTS
Adverse Incident (Clinical)
An event or circumstance arising during clinical care
of a patient that could have or did lead to unintended
or unexpected harm’.
Adverse Incident (Non-Clinical)
‘An event or circumstance that could have or did
cause unexpected or unwanted harm, loss or damage to
any individual(s) involved (including patients but not
related to clinical care, staff, visitors etc) or damage
to/loss of property/ premises in the hospital .
It should be reported with in 2 hrs

7. SENTINAL EVENTS
An unexpected incident, related to system or process
deficiencies, which leads to death or major and
enduring loss of function for a recipient of healthcare
services.
It should be reported immediately.

8. INCIDENT REPORTING
(STAFF)
It is a requirement of all Hospital staff that they report
any incident, accident or potential incident which has
caused or has the potential to cause harm, loss or damage
to any individual involved or loss or damage in respect
of property premises for which the hospital is
responsible.

9. HOW TO REPORT AN
INCIDENT
● Obtain the proper forms from your institution.
Each institution has a different protocol in place
for dealing with an incident and filing a report.
● Start the report as soon as possible. Write it the
same day as the incident, if possible, because if
you wait a day or two your memory will start to
get a little fuzzy. You should write down the
basic facts you need to remember as soon as the
incident occurs, and do your report write-up
within the first 24 hours afterward.

10. ● Provide the basic facts. Your form may have
blanks for you to fill out with information
about the incident. If not, start the report with a
sentence clearly stating the following basic
information given in the Incidence form.
● Write a first person narrative telling what
happened. For the meat of your report, write a
detailed, chronological narrative of exactly
what happened when you report to the scene.
Use the full names of each person who is
included in the report, and start a new
paragraph to describe each person's actions
separately.

11. ● Be thorough. Write as much as you can remember -
the more details, the better. Don't leave room for
people reading the report to interpret something the
wrong way. Don't worry about your report being too
long or wordy. The important thing is to report a
complete picture of what occurred.
● Be accurate. Do not write something in the report
that you aren't sure actually happened.
● Be clear. Don't use flowery, confusing language to
describe what occurred. Your writing should be
clear and concise. Use short, to-the-point, fact-oriented
sentences that don't leave room for
interpretation.

12. ● Be honest. Even if you're not proud of how
you handled the situation, it's imperative that
you write an honest account. If you write
something untrue it may end up surfacing later,
putting your job in jeopardy and causing
problems for the people involved in the
incident.
● Submit your incident report. Find out the name
of the person or department to whom your
report must be sent. When possible, submit an
incident report in person and make yourself
available to answer further questions or
provide clarification.

13. PERSON RESPONSIBLE FOR THE
IMMEDIATE MANAGEMENT OF
THE INCIDENT
The person responsible for the immediate
management of the incident (e.g. the nurse in charge
of the ward at the time an incident occurs), should
undertake an immediate assessment of the situation,
in order to determine any immediate treatment
and/or ongoing care needs of the affected person,
and/or the extent of any loss/damage to property and
any other immediate action required (e.g. removal
and isolation of faulty equipment). The
situation/scene should be made safe.

14. ROOT CAUSE ANALYSIS
Root Cause Analysis’ is a structured investigation
process that aims to assist in the identification or the root
or underlying cause(s) of a particular event or problem
by determining WHY the failure occurred and the
actions necessary to prevent or minimize the risk of
recurrence.
A ‘Root Cause’ is a failure in a process that, if
eliminated, would prevent an adverse incident occurring.
Training for the relevant staff on incident
grading/investigation and root cause analysis will be
provided as part of the risk management training
programme.

15. FAIR BLAME CULTURE
In an organization as large and complex as the
Hospital, things will sometimes go wrong. The
wrong assessment should not be one of blame
and retribution, but of learning,a drive to reduce
risk for future patients and staff. Blame cannot,
and should not, be attributed to individual health
care professionals. Identifying and addressing
dysfunctional systems is, therefore, the key to
reduce the risk of harm for many patients and
staff through incident form.

16. It is understood that fear of disciplinary
action and subsequent sanctions may
discourage the staff from reporting
incidents, therefore,continues to be
developed within a culture of ‘fair blame’.
The Management approach following
incidents will therefore focus on ‘what
went wrong, and not who went wrong’.