Incident Reporting in Healthcare

The hospital's risk management program employs a number of systems to identify and provide notification of incidents or events that have occurred involving patients, visitors, staff, equipment, facilities or grounds which are likely to give rise to potential liability, affect the quality of patient care or affect safety in the hospital. The early identification of such occurrences allows the hospital to immediately investigate the circumstances of the incident, and if necessary, institute corrective action to prevent similar occurrences in the future. One of the systems used to identify and report patient and visitor related occurrences is the hospital's incident report system.
Health care providers and other hospital employees are required to report and complete a Report of Incident form (F-877) regarding any patient or visitor who, while within hospital jurisdiction and/or while on hospital premises, is involved in an occurrence which has caused or has the potential to cause injury or loss or damage to their personal property. This includes incidents where the possibility of injury existed although no injury was actually incurred and those incidents which are inconsistent with the routine care of a particular patient or routine operation of the hospital.
The following are some examples of reportable incidents:

• Error in the care of patients (e.g., errors in the administration of medications, treatments, mismatched transfusions, retained foreign bodies following surgery, etc.).
• Development of conditions seemingly unrelated to the disease for which the patient was admitted (e.g., pressure sores, pediculosis, diarrhea or impetigo in the Newborn Nursery, etc.).
• Adverse or suspected adverse reactions to a manipulative procedure, medication or transfusion.

All health care providers should be familiar with the complete hospital incident reporting procedures which can be found in the Yale New Haven Hospital Administrative Policy and Procedure Manual, I-3. The following is a brief discussion of the procedures involved in incident reporting.
For incidents involving patients, the person completing the Report of Incident form should be the individual who witnessed, first discovered, or is most familiar with the incident. Each section of the form must be completed according to the directions on the form. The report must then be immediately presented to the reporter's supervisor who must then investigate and recommend corrective action. The description of the incident should be a brief narrative which should consist of an objective description of the facts. It should not include the writer's judgment as to the cause of the event. Quotes should be used where applicable with unwitnessed incidents, e.g., "Patient states..." The name of any witnesses should be included on this report. The name of the employee directly involved in the incident can be recorded in the witness space as well, if the employee is not the reporter. The patient must be examined by an appropriate physician, who should complete the appropriate section on the form regarding his or her findings. The Report of Incident form should be completed no later than the end of the shift during which the incident occurred or was discovered to have occurred and must be forwarded to the Central Nursing Office within 24 hours and the Office of Legal Affairs within 48 hours.
All incidents involving visitors must be reported to the supervisor in the area where the incident occurred. A visitor who has sustained an injury while in the hospital should be escorted by a staff member to the Emergency Service for medical attention. If the injured person refuses medical attention, this must be noted on the Report of Incident form.
The Report of Incident form is an administrative document, not part of the medical record. The fact that an Report of Incident form has been completed should not be reflected in the medical record, nor should the report be placed in the medical record. In addition, no copies of the Report of Incident form may be made. An objective description of the incident should be recorded in the medical record by both the medical and nursing staff along with any follow-up observations, diagnostic studies and results, and/or related treatment.
Whenever a patient or visitor incident is of an unusual or serious nature, the Office of Legal Affairs must be called immediately.
If a medical device is involved (caused or contributed to death of, serious injury to, or serious illness of a patient):

• report the incident to Nurse Manager/designee;
• notify the Office of Legal Affairs
• fill out a device incident report form;
• record the manufacturer, model number, serial number, and control number of the equipment on the incident report;
• save the original packing if possible;
• when equipment is involved, impound the equipment, the disposable product used with the equipment, and the packaging materials from the disposable product;
• tag the equipment with a sign that states "EQUIPMENT BROKEN - DO NOT USE";
• notify Medical Engineering that you have a piece of equipment that has been involved in an incident and requires evaluation.