Things You Need To Know About The Incident Report In Nursing For 2024

Posted 27.01.21 by:

Updated June 3, 2024.

Understanding when and why you need to approach a situation as an incident is sometimes confusing for those minor situations that may seem like they are not worth mentioning. But what exactly constitutes a situation or event where you must file an incident report in the nursing field? 

A minor event may not be significant enough for you to stop what you’re doing and fill out an incident report in a busy ward. That is until it becomes a liability for you and your facility. Here’s the first thing you need to know about the incident report in nursing:

1. What Is An Incident Report In Nursing?

An incident report in nursing is a report which details an event where a person is injured, or property is damaged. If these conditions occur on medical facility property, completion of an incident report is necessary.

Now that we’ve defined the first of four things you need to know about incident reports in nursing, let’s look at the others. 

Some healthcare facilities have standards that are different from others, so we’ll define a baseline standard, and you can use this relative to your facility’s reporting standard. Even if the standards are different, the concept will remain the same. So, join us in examining the incident report in the nursing field and four things you need to know.

2. When To Report an Incident Report

There are going to be times when reporting an incident is a no-brainer. For example, a patient slips and fractures their arm. That’s a severe injury from a simple slip, but it happens more times than you might think. What if a patient stubs their toe on an IV cart wheel while going to the restroom?

Many situations seem trivial and not worth reporting. In some cases, nurses fear reprisals for having an incident in their ward. So, sometimes, they fear reporting any incident, albeit trivial ones, even though it is in their best interest to do so.

How do you define a severe incident worthy of reporting from a minor one? Each facility will likely have its version of these definitions. Indeed, no hospital practices medicine without a team of lawyers deciding what is or isn’t worthy of note-taking. But, in case your facility’s policies seem a little lax in the explanation department, let’s see if we can lend a hand to your dilemma.

Regarding liability, we’re not lawyers, and you should always seek legal advice. However, we know a thing or two about incident reporting. And it seems fitting that an event becomes a reportable incident when it meets one or both prerequisites:

  1. A person sustains an injury.
  2. Property sustains damage.

Want to know how your incident reporting program could send instant notifications when an injury or property damage incident report is completed? Try the 1ST Reporting app and discover what digital reporting can do for your facility.

When A Person Is Injured – File An Incident Report

When devoid of a clear and concise plan, the simplest way is to report any injury. It could be as minor as a paper cut in this case. There is no grey area defined, so it’s simple to understand. Any injury requires a report. 

With this definite ruling in practice, a medical facility has the best chance of catching and correcting potential hazards. The potential for an improved standard of care for patients becomes evident when there is no grey area in an incident reporting program.

When Property Is Damaged File An Incident Report

Similar to an incident report in nursing for injuries, you can include a polarized property damage reporting policy in your reporting practices. That is to say, incident reporting happens if damage occurs. The approach is black and white, with no grey area for misinterpretation.

With a reporting strategy of zero tolerance, nothing escapes reporting; minor damages are all reportable. It could be as simple as an IV or med cart’s wheel breaking or a broken mirror due to a patient’s outburst. No matter the cause, if the property is damaged, it should fall into the required reporting category.

3. What To Report

A woman is injured from a fall in a hospital room accident. Learn about reporting incidents and accidents in nursing at

We’ve discussed when to report without a clear and concise reporting procedure for your medical facility. However, determining what to write is a slightly different topic. Why? We must clarify what constitutes injury or damage to a person or property. It’s this definition that may have a grey area of its own that can, in some situations, cast doubt upon whether or not to file a report.

Nurses know that sometimes you’re busy – extremely busy! There are near-miss incidents every minute in a busy ward, just stand and watch a swinging entrance door, and you’ll see multiple safety close-calls. But it doesn’t stop with doors; there are safety concerns around every corner in medical facilities.

And how should one define an injury? A minor paper cut may heal in a day or two, so does it count? If a ward is bustling and the nurses are busy, there is a likely chance that nurses may avoid an incident report for minor concerns like paper cuts or stubbed toes.

But what happens when a patient returns with a lawyer six months later and demands restitution for alleged mistreatment for some minor paper cut or toe-stubbing incident? If there is no record, you may stand little chance of defense.

The lesson to this dilemma is always to file an incident report if you are notified of an injury, no matter the severity. It’s the only way to ensure that you’ve got a record to fall back on later to protect yourself and your work facility.

Learn 12 things to include in an incident report (with five tips on writing the report better).

4. Why Nurses Need To File An Incident Report

There are five primary reasons why nurses need to complete incident reports: 

  1. Personal Liability
  2. Facility/Organization Liability
  3. Enhanced Patient Care And Facilities
  4. Improved Workplace Safety Culture
  5. Improved Restitution Process

Personal Liability

Morally, we’re supposed to ignore personal liability and ‘just do what’s right.’ However, in a world where people throw lawsuits like we throw candy to children on Halloween, you’ve got to cover your bases.

No one wants to think they will be named in a lawsuit, but it happens daily. So, merely for personal liability, nurses should complete incident reports with every event that includes property damage (or loss) or injury to anyone.

Facility/Organization Liability

It doesn’t look right to get fired. No one wants to lose one’s job. Worse yet is to get blackballed in your area due to a facility administration getting sued over something you neglected to report. It is not an issue of personal liability (but, in a way, it could be).

Keeping your facility out of hot water by maintaining a strict incident reporting regiment is a wise practice. 

Enhanced Patient Care And Facilities

Documenting incidents of every type is the only way that safety and operations managers can implement new, evolved, or replacement procedures. From a simple material change to a procedural makeover, a facility cannot improve its functions without documentation of how an incident came to pass. And we all want a better working environment that strives to improve. In medical facilities, a minor improvement could make the difference between life and death for a patient.

Improved Workplace Safety Culture

In any organization, whether a medical facility like a hospital, a clinic, or another medical establishment, one thing is right. When everyone follows the rules, it’s easy to follow them yourself.

It is valid for incident reporting in the nursing community as well. No one becomes the oddball out when everyone joins the team effort to improve safety.

Improved Restitution Process

Hospitals are, unfortunately, places that see a lot of incidents. People from every walk of life find their way to hospitals for one reason or another. Sometimes, incidents occur, such as a person’s belongings being stolen. If someone tells a busy nurse of the infraction, but the nurse does not file a report, how will administrative staff know what restitution is deemed fitting given all the facts?

Documenting all incidents within a medical facility is critical for nurses to aid in maintaining safe and fair facilities. The goal should be for facilities where patients, visitors, and staff alike are treated with dignity and respect. That means they have the right to make claims and find reward in restitution if the situation warrants it.

The Final Thought On Incident Reporting For Nurses

The best advice is always to complete an incident report when an injury or damage occurs. A good facility management team will embrace an open reporting policy and discourage retribution to any nurse who does their duty by completing an incident report.

In any case, the only way to truly protect yourself is to complete a report and complete it factually and without judgment or bias. Completing factually and indiscriminately ensures that you genuinely cover your bases and don’t just create further headaches to deal with in the future.

Learn more about why you should complete incident reports.

Frequently Asked Questions

How do you write an incident report in nursing?

A nurse completes an incident report using a tablet.

Writing an incident report in nursing is similar to writing an incident report in other industries. Following a procedure of steps when writing an incident report ensures uniformity of reporting processes and conformance with facility regulations.
Learn more here about how to write a complete incident report in only 11 steps.

What are examples of an incident (in nursing)?

Incidents in nursing can range from a wide variety of events and situations. Some examples of incidents in the nursing world are:
– accidental needlesticks
– trips, slips, and falls
– medication errors

What makes a good incident report?

A good incident report is a report that includes the vital pieces of information needed to document the incident. There are four things the writer can do to ensure the document is superior:
1. Write factually and impartially.
2. Never place judgment, blame, or make assumptions in the report.
3. Only report facts, not feelings or impressions.
4. Record data to the best of your ability quickly and efficiently while maintaining descriptive information gathering.

What is the purpose of an incident report?

The purpose of an incident report is to document any event that could affect the safety, health, or well-being of patients, staff, or visitors. These reports provide a clear and detailed account of incidents, helping healthcare facilities identify and address potential risks. Incident reports serve as valuable tools for improving patient care, enhancing safety protocols, and ensuring compliance with regulatory standards. They also protect healthcare providers by providing a factual record of events, which can be crucial in legal or administrative proceedings.

How to write an incident report for a nurse?

Writing an incident report for a nurse involves several key steps:
1. Immediate Documentation: Write the report as soon as possible after the incident to ensure accuracy.
2. Objective Description: Describe the incident objectively, including the date, time, and location. Avoid subjective language or assumptions.
3. Details of the Incident: Include a detailed account of what happened, who was involved, and any witnesses. Mention any actions taken immediately after the incident.
4. Patient Information: Provide relevant patient details, such as name and medical record number, while maintaining confidentiality.
5. Outcome and Follow-up: Document the outcome of the incident and any follow-up actions or interventions taken to address the situation.
6. Sign and Submit: Ensure the report is signed and submitted according to your facility’s protocols.

Which situations require an incident report?

A senior hospital patient falls to the floor, spilling medications.

In nursing, several situations necessitate an incident report, including:
1. Patient Falls: Any fall, regardless of whether it results in injury, should be reported.
2. Medication Errors: Mistakes in prescribing, dispensing, or administering medication.
3. Needlestick Injuries: Any injury involving needles or other sharp objects.
4. Patient Elopement: When a patient leaves the healthcare facility without authorization.
5. Equipment Failures: Malfunctions or failures of medical equipment that could impact patient care.
6. Violence or Abuse: Incidents involving physical or verbal abuse towards patients or staff.
7. Infections: Any incident involving the spread or potential spread of infection within the facility.
These reports are crucial for maintaining a safe and effective healthcare environment, ensuring that all incidents are properly addressed and mitigated.

Now, get out there and keep making a difference in improving your safety and those around you. Good reporting and safety come to those who make it happen.

Sources and Resources

  1. Wikipedia Contributors. 2023. “Incident Report.” Wikipedia. Wikimedia Foundation. May 17, 2023.
  2. ‌Besmer, Michelle, Toby Bressler, and Catherine Barrell. 2010. “Using Incident Reports as a Teaching Tool.” Nursing Management 41 (7): 16–18.
  3. ‌Iedema, Rick, Arthas Flabouris, Susan Grant, and Christine Jorm. 2006. “Narrativizing Errors of Care: Critical Incident Reporting in Clinical Practice.” Social Science & Medicine 62 (1): 134–44.
  4. ‌P. Kantelhardt, M. Müller, A Giese, V Rohde, and S R Kantelhardt. 2009. “Implementation of a Critical Incident Reporting System in a Neurosurgical Department.” Central European Neurosurgery 72 (01): 15–21.
  5. ‌Okuyama, Ayako, Minako Sasaki, and Katsuya Kanda. 2010. “The Relationship between Incident Reporting by Nurses and Safety Management in Hospitals.” Quality Management in Health Care 19 (2): 164–72.

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