Incident Reporting

Incident Reporting
Fast-Tracking Information, Nothing More, Nothing Less?

Incident reports are an important source of information in ambulatory surgery centers (ASCs). When used appropriately, incident reporting is not a punitive process, but rather it is a method to record injury or potential injury to patients, visitors, and employees, and to relay this information to the appropriate person — such as your risk manager or administrator — for action. This allows early intervention and the potential to eliminate, reduce, and manage any subsequent claim or lawsuit.

Incident reports are an important source of information in ambulatory surgery centers (ASCs). When used appropriately, incident reporting is not a punitive process, but rather it is a method to record injury or potential injury to patients, visitors, and employees, and to relay this information to the appropriate person—such as your risk manager or administrator—for action. This allows early intervention and the potential to eliminate, reduce, and manage any subsequent claim or lawsuit.

Accurate and timely incident reporting:

• Improves patient, visitor, and employee safety 
• Identifies potential losses and claims 
• Documents the facts on a timely basis 
• Facilitates investigation while information is fresh and available 
• Provides early intervention if corrective action is needed 
• Collects data for detecting trends, patterns, and needed systems changes 

Incident reports should merely document the facts of an incident for investigation and analysis. They should be used to identify risks and provide a basis for any corrective measures that are needed to prevent the future occurrence of a similar event. It is important for your ASC’s management team to communicate that incident reporting is not intended to be an admission of any wrongdoing or a vehicle for blame. Rather, incident reporting is the responsibility of all staff, in all areas, in order to promote patient safety, prevent employee injury, and to improve patient care and staff performance.

It is essential for every staff member to know and follow your ASC’s policy and procedure for reporting incidents. The policy should define what an incident is, explain what should be done after an incident occurs, and determine who has responsibility to complete the report and provide instructions on how to complete the paperwork. Common examples of ASC incidents often include:

• Safety-related incidents — whether patient, visitor, or staff, such as slips and falls 
• Diagnosis or treatment-related occurrences, such as a hospital admission 
• Communication-related events, such as a procedure performed without informed consent 
• Drugs and Intravenous-related incidents, such as wrong medication dose, IV solution, rate, or time 
• Surgery/anesthesia-related errors, such as wrong patient or wrong site 
• Equipment-related mishaps, such as an equipment malfunction 
• A dissatisfied patient or family member

An incident report should be completed immediately after the event occurs or is discovered by an individual with first hand knowledge of the event. It should be forwarded to the risk manager or administrator as soon as possible. Serious incidents should be reported immediately whether in person or by telephone. Your incident report forms should include state-specific peer review or quality assurance language to ensure the greatest evidentiary protection afforded in your state. The information contained in it should be treated as confidential, and distribution should be limited on a need-to-know basis.

Elements of a good incident report include:

• Person affected — patient, employee, visitor 
• Date, time, and location of incident 
• Factual description of incident 
• Comments about the event from the affected person 
• Observations of the incident scene 
• Eyewitness statements 
• Identification of medical devices involved 
• Physician notified and response 
• Condition of the affected person 
• Date and time the incident report was completed

First, assess the person and provide any clinical care that is needed. After the individual has been stabilized, notify the physician and risk manager or administrator. Document the clinical assessment, any physician orders, and treatments in the medical record. Record the person’s or witnesses’ comments. Impound any equipment or supplies that may have been involved in the event; do not return them to the manufacturer. If necessary, an independent third party should perform any testing. Complete the written incident report. If the reporting of an incident by a patient or family member is delayed, document the time of the notification and the reason for the delay. Do not discuss the event with the media or with any other outsider. Determine who will disclose the event to the person and when.

Limit documentation of the response to the incident to:

• Who assisted the person involved in the incident 
• The name of the risk manager or administrator that was notified 
• The name, date, and time of physician notification 
• The extent of the injury 
• Details of hospital transfer or discharge 
• The status of the person upon transfer 
• The parties included in the disclosure conversation as well as the content of the conversation 

When writing in the medical record, document only the occurrence and the response, and do not make reference that an incident report was completed. Most importantly, do not put incident reports in patient records.