How To Write an Incident Report

Amber Ratcliffe

In healthcare, safety and quality of care are paramount. Medical incident reports are tools that contribute to improving both patient care and workplace safety by shedding light on accidents and near misses, training gaps, and areas where practices may require adjustments. But to get the most out of these reports, healthcare professionals need to know how to write an incident report.

Well-written, comprehensive incident reports are critical, and an online incident reporting system can help streamline the process.

What Is an Incident Report in Healthcare?

An incident report is a document that outlines and details any unexpected or adverse events that occur within a healthcare facility. Incident reports are an important part of maintaining healthcare standards and regulatory compliance. Proper completion and storage of reports are crucial for audits and regulatory adherence, and records must be maintained for five years.

Beyond being a tool for internal assessment, these reports are mandated by organizations like the Occupational Safety and Health Administration (OSHA) to promptly report incidents causing death, serious injury, or hospitalization .

Steps To Write an Incident Report

Incident reports are, by nature, extremely detailed documents. Because their purpose is to not only record an incident but to help prevent future similar problems, they need to be well-written and descriptive. As a result, knowing how to write an incident report requires a systematic, comprehensive approach:

Diagram of MedTrainer

  1. Includebasic information. Begin with the date of the report, the date and time of the incident, your name, job title, and contact information. Specify the location of the incident and indicate whether similar incidents have occurred before at the workplace.
  2. Describe what happened. Provide a clear, chronological account of the events leading up to the incident. Be specific and precise. For instance, if reporting a medication error, include details such as the brand name, manufacturer, and the exact nature of the error. Include the names, contact details, and identifying information of individuals involved.
  3. Describe the consequences. Outline the consequences of the incident, including any injuries or damages sustained. If applicable, describe the required treatment for injuries or any impact on the involved parties. If possible, include photographs or diagrams to visually depict the incident scene.
  4. Include documentation. Attach relevant evidence or documentation related to the incident. This could involve transcripts of conversations, audio recordings, or any other information that provides context and clarity.
  5. Explain corrective actions. Detail the actions taken in response to the incident. Specify who was involved and the timing of these actions. This may involve stabilizing patients, notifying supervisors, revising protocols, conducting training, or initiating a root cause analysis.
  6. Escalate the incident report. In most cases, incident reports require review by relevant personnel. Online incident reporting systems simplify this process, automating the escalation of reports to the appropriate individuals or departments.

Why Use an Online Incident Reporting System?

Healthcare is fast-paced and every mome nt counts where patient safety is concerned. Having an efficient incident reporting system is more than just a convenience — it’s a necessity. Traditional paper-based incident reporting methods have given way to online incident reporting systems, revolutionizing the way healthcare organizations handle incidents, near misses, and safety concerns.

Here’s why healthcare facilities are increasingly turning to online incident reporting systems to bolster safety, streamline processes, and enhance overall efficiency:

Use MedTrainer for Your Medical Incident Reports

The value of safety, efficiency and continuous improvement can’t be overstated. Online incident reporting systems embody these principles, revolutionizing incident management, analysis, and prevention. By embracing technology, healthcare organizations can keep patients safe, support their staff, and elevate the overall quality of care.

With the right incident reporting system — like MedTrainer — your practice can create a culture of transparency, data-driven decision-making, and swift intervention. Learn more about MedTrainer’s incident reporting system today.