Incident Reports All organizations have specific forms, along with policies and procedures to complete for incidents. In the past, the forms were called accident reports. However, this terminology is now dated as all types of incidents use the same reporting methods to report any issue that results in or could result in harm to any person. Incident reports apply to both employee incidents and patient incidents. The purpose of incident reporting is to document the exact details of what occurred while the situation is still fresh in the minds of those who observed the event. The report does become a permanent record often filed in a human resources file for an employee with a duplicate to the compliance officer for complete recording of issues or situations in the organization. Patient incident reports are kept by the compliance officer. Patient incident reports are generally not part of the patient medical records. The reports are often needed in liability cases where patient harm or a patient error occurred. Incident reports generally involve patients. However, most health care organizations will complete incident reports on employees, visitors, and others who are involved in any sort of incident where injury or harm could have occurred. For example, a visitor slipping and falling on ice in the parking lot would require an incident report. Anyone who actually observed the occurrence will be asked to complete an incident report. The compliance officer will want these documents completed as soon as is feasible once the injured person or patient is stable or safe. The compliance officer will not want reporters to compare notes. It is important that each person completes the report as accurately as possible from their own viewpoint. At times, observers may want to embellish the details or provide information about outcomes or information not related to the actual incident. For this reason, the compliance officer’s investigation will often include a one-on-one interview with each observer to insure that the information is accurate. Many health care organizations also have security cameras in all common areas in and around the facility. The compliance officer may review this type of data, too. These types of videos are generally only part of an investigation. Cameras only collect certain angles of action. After the completion of incident report forms, the compliance officer will begin an investigation looking for any issue that could be avoided in the future. The compliance officer may interview all of the observers as well as the person who was involved in the initial incident. A few examples include: A visitor who gets his hand caught in the door of the elevator and has a crush injury to three fingers. The elevator will need to come out of service to ensure that it opens immediately upon hitting any type of obstruction. A patient who gets entangled in IV tubing and falls. The staff will need training on how to manage tubing and wiring attached to the patient to avoid entanglement. An occupational therapist who burns her hand on the heating element to create hand splints. A review of equipment procedures; ensure that the heating element is inspected by maintenance; and retraining for proper use. Visitors’ cars that are hit by flying rock following the landing and take-off of a medical helicopter. The landscaping rock may need to be removed in favor of shrubbery. Car insurance claims will need to be filed and paid by the organization. Procedures related to which parking areas need to be cleared when a helicopter will be landing will need to be reviewed. Medical Errors There are also specific incident reports for medical errors. Medication errors, wrong site surgical errors, and misplaced pathology reports are all examples of more specific reporting that will be handled by the clinical leadership, quality assurance director, and compliance officer. A typical incident investigation surrounding a medical error has several goals: to identify what happened; the problems that occurred related to this event; and the factors that contributed to this occurrence. The involved committee will look at physical artifacts (for example, a loose railing, water on the floor, ice in the parking lot, broken equipment, items used for the wrong purpose); patient records; and witness statements. Many incidents require reporting as “sentinel” events. The Joint Commission (TJC) also has language related to “never” events—situations that occur which should never have occurred. Most medication errors are classified as never events. Wrong site surgeries are always never events, too. TJC considers a sentinel event any unanticipated event in a healthcare setting that results in death, serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness. TJC gathers data from TJC accredited hospitals into databases. The database is known as The Joint Commission’s Sentinel Event Database. The database is used by both TJC and state departments of health to determine accreditation for hospitals. The state department of health can add other sanctions to ensure that the hospital is acting in the most efficient manners to continually reduce sentinel events. Hospitals that are not able to make actionable changes risk losing Medicare and Medicaid reimbursement. Health plans generally follow the lead of the entitlement programs. Sentinel events are harmful to patients, the clinicians, and to the financial viability of hospitals. Not all hospitals are TJC accredited. There are other accrediting bodies, too. All state departments of health also keep sentinel event tracking databases. Each state’s database is different. You may want to investigate what you find in your own state. Also, most state departments of health publish the information on sentinel events yearly in newspapers and other public venues. The public does have the ability to know what types of sentinel events occurred in the hospitals that serve the community. The Centers for Medicare and Medicaid collect and track sentinel event reporting. The public reporting keeps the public informed. However, the more important piece is payment. Hospitals that have unmanaged sentinel events risk losing their licenses to operate and certainly risk losing payment from the major payers of Medicare, Medicaid, and health plans. Your role in health care is to keep an eye out for correct procedures and patient safety. Be observant. Report the information from your own viewpoint. Be accurate. Complete the documentation required. Report any unusual issues to your supervisor. Level 1 Short answers: • Follow assignment directions. • Write answers in your own words, no copying and pasting from websites or other sources. Use complete sentences and well- formed paragraphs with appropriate syntax. • Avoid using contractions and personal pronouns. Proofread, check spelling and grammar prior to submission • Use correct punctuation and capitalization. Level 2 Informal essays or projects: • Incorporate all Level 1 guidelines. Use effective paragraph transitions Include a clear introduction, body, and conclusion. Use Arial or Times 12-point font Double-space your text Set page margins to one inch Use reliable sources, cited properly within the text and listed on a references page when indicated.
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