incident reporting

Documenting and Reporting Incidents in the Workplace

As a nurse, it’s your job to document and report any incidents that might occur when caring for patients. From accidents to patient complaints, a lot can happen when you’re spending time with a patient. It’s your responsibility to pass that information along to your supervisors and medical personnel using incident reports. Learn more about documenting incidents in the workplace and how you can use new technology to your advantage.

What Is an “Incident” and Why You Should Report It

In the field of nursing, an incident is generally described as a situation in which something out of the ordinary occurs. While this definition is vague, nurses are often directed to use their judgement. What qualifies as an incident varies depending on the facility in question.

Incidents usually fall into one of these categories:

  • Someone, either you, the patient or a visitor, is injured, or a situation occurs with the potential for injury (i.e. a patient slips and falls, or you prick your finger when drawing the patient’s blood)
  • A medication error occurs in which the patient missed their medication or took the wrong pill
  • A medical device malfunctions and needs to be repaired or replaced
  • The patient has a complaint about their experience at the facility

Remember to use your judgement when caring for patients and be on the look out for anything out of the ordinary. If you make a mistake while caring for the patient, don’t be afraid to report the mistake. Being honest and accurately documenting your experiences on the job are part of your responsibility. When in doubt, put yourself in the shoes of the doctor or facility manager and ask yourself if this information is something they need to know. You can always ask your supervisor or manager if the incident needs to be reported.

Over time, you will learn what qualifies as an incident, so you can do your job quickly without always second-guessing your instincts.

New Documentation and Incident Reporting Technology for Nurses

Thanks to improvements in healthcare technology, documenting and reporting incidents on the job has become much easier than it used to be. Instead of cumbersome paper forms, nurses can now upload incident reports to a patient’s file using electronic health records and special digital incident forms. You can quickly select the particular type of incident report you need, enter some key information into the computer, and attach the report to the patient’s file.

Using these automated digital forms makes it easier to manage and organize incident reports. If an incident occurs on the job, you or your supervisor can quickly search for the patient’s record and see the details of what happened. These digital forms are also easily sharable. If a patient is transferred to another department or wing of the facility, you can pass off their information, including all incident reports, to the patient’s new healthcare provider. You and your supervisors don’t have to worry about valuable information getting lost in the shuffle.

Use digital incident reports to keep track of your experiences with the patient to make sure everyone has the information they need to deliver the best possible care.