Incident Reports


An incident report is not part of the patient’s chart, but it may be used later in litigation. A report has two functions:

  1. It informs the administration of the incident so management can prevent similar incidents in the future.
  2. It alerts administration and the facility’s insurance company to a potential claim and the need for investigation.

Regulations issued under OSHA require all employers with more than ten employees at any time during the previous calendar year to maintain records of recordable occupational injuries and illnesses.

When to Report

Incidents that must be reported and documented include:

  1. Exposure Incidents: skin, eye, mucous membrane or parental contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
  2. Accident, Injury: patient, visitor, employee slips or falls, or other incident, which results or may result in injury.
  3. Event, Behaviors, or Actions: incidents that are unusual, contrary to agency policy or procedure or which may result in injury.
  4. Vaccine Adverse Event Reporting System: reaction to vaccine administered at agency (use VAERS form, instructions and sample in Immunization section).
  5. Medication reaction: reaction to any drug administered at or provided by health department. Complete Adverse Drug Reaction Form. For more information,call 1-800-332-1088.
  6. Property damage or missing articles.
  7. Administration of wrong medication or vaccine.
  8. Improper administration of medication or vaccine.


Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems.

Characteristics of Incident Reporting Systems

An effective event reporting system should have four key attributes:

Box. Key Components of an Effective Event Reporting System
  • Institution must have a supportive environment for event reporting that protects the privacy of staff who report occurrences.
  • Reports should be received from a broad range of personnel.
  • Summaries of reported events must be disseminated in a timely fashion.
  • A structured mechanism must be in place for reviewing reports and developing action plans.


  • All sampled hospitals had incident reporting systems to capture events, and administrators we interviewed rely heavily on these systems to identify problems
  • Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm
  • Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and led to policy changes
  • Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected



EMPLOYEE: Return this COMPLETED FORM to your SUPERVISOR as soon as possible.

Name of Person Involved: ______________________________________________________________

Address: ____________________________________ City: ___________________________________

Phone Number: _____________________ Age: ________ DOB: _____________ Sex: M ____ F _____

SS#: _________________________ Date of Incident: _____________ Time: ______ am/pm

Exact Location of Incident: ______________________________________________________________

Check Type of Accident: Check:

  • Clerical/Data Entry _____ Patient

  • Communications _____ Employee

  • Testing Process _____ Visitor

  • Result reporting _____ Volunteer

  • Safety _____ Other

  • Medical Device Failure

  • Policy/Procedural Violations

  • Adverse Drug Reaction

  • Vehicle Accident

  • Needlestick

  • Exposure to Hazardous Substance

  • Medication Error (Wrong: Route, Dosage, Medication, Schedule)

EMPLOYEE: Involved _____ yes _____ no

Were they doing their regular job duties: _____ yes _____ no Observed by employee yes

Hire Date: ____________ Marital Status: ____________ Situation observed only by employee yes

Employee Classification: ______________________________

Protective Equipment being used: _____ yes _____ no

If not used, Why: ___________________________________________________________________________________


Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events, personnel involved, body part injured, reason incident occurred) (If medication error include brand name, manufacturer, dosage) (Use additional form if necessary)






Actions Taken by Staff Members: _________________________________________________________




Witness Name: ________________________________ Phone Number: _________________________

Address: ___________________________________________________________________________

Witness Name: __________________________________ Phone Number: _______________________

Address: ___________________________________________________________________________

MEDICAL FOLLOW-UP: Was Medical Attention Sought: _____ yes _____ no

Treatment Refused: _____ yes _____ no First Treatment Date: _____________________________

Treating Physician: ________________________________ Phone Number: ____________________

Address: ___________________________________________________________________________

First Day Off Work: _________________________ Return to Work Date: _______________________

Duties Restricted: _____ yes _____ no Explain: ___________________________________________


Incident Reported By: __________________________________ Date: ________________________

Supervisor Notified: _____ yes _____ no Date: _________________ Time: _______________

Name of Supervisor: __________________________________________________________________

Signature and Title of Person Preparing Report: ______________________________ Date: _________

Supervisor Comments: ________________________________________________________________


Supervisor Signature: ___________________________________________________ Date: ________

Corrective Action Taken/Follow-Up: (Things that have been or will be taken to prevent recurrence)


Director Comments: ___________________________________________________________________


Director Signature: ______________________________________________________ Date: ________

Nursing Administrator Signature: ___________________________________________ Date: ________

Administrator Signature: __________________________________________________ Date: ________

Signature of Person making Complaint: ______________________________________ Date: ________

Worker Compensation first Report Sent: _____ yes _____ no Date: _______ OSHA 300 Log # : ______

_____ I understand the potential risks related to the exposure to the incident that occurred and agree to receive an examination and/or treatment for the exposure, as recommended by my physician. This includes serological testing for Hepatitis B and the HIV virus as indicated.

_____ I understand the potential risks related to the exposure incidents that occurred and DO NOT agree to have an examination or treatment for the exposure.

Employee Signature: _________________________________________________ Date: ___________

Supervisor Signature: ________________________________________________ Date: ___________

I understand the information above will be used by my employer to help determine liability for injury. I acknowledge that the above statements are true and accurate representation of the requested information.

Employee Signature: ___________________________________________________ Date: _________

Job Title: ___________________________________________

Testing for HBV: Baseline and 6 months*

Testing for HIV: Baseline, 6 weeks, 3 months, 6 months, and 1 year**