How to Write a Nurse Incident Report

Young Asian-American female nurse wearing mask, white lab coat, and stethoscope taking notes on a clipboard in the middle of a hallway.

If you dread writing incident reports, you might take comfort in knowing that you’re not alone. Stressing over getting the report done or about what to include are common concerns for nurses — not to mention worrying about whether filing the report reflects badly on your performance. Mistakes happen all the time, and healthcare facilities are not immune. According to a 2016 study conducted by Johns Hopkins, medical errors have become the third-leading cause of death in the U.S. and threaten the safety and well-being of patients. As time-consuming as incident reports may be, their role in patient care cannot be ignored.

What Is an Incident Report?

An incident report is an electronic or paper document that provides a detailed, written account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting. The incident doesn’t have to have caused harm to a patient, employee, or visitor, but it’s classified as an “incident” because it threatens patient safety.

To ensure the details are as accurate as possible, incident reports should be completed within 24 hours by whomever witnessed the incident. If the incident wasn’t observed (e.g., a patient slipped, fell, and got up on his own), then the first person who was notified should submit it. For the most part, these incident reports are completed by nurses or other licensed personnel and are used for risk management, quality assurance, educational, and legal purposes.

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What’s the Purpose of an Incident Report?

Incident reports are used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for the following purposes:

  1. Risk management. Incident report data is used to identify and eliminate potential risks necessary to prevent future mistakes. For example, if an incident report review finds that most medical errors occur during shift changes, risk management teams may suggest that nursing staff develop standardized turnover protocols to avoid future errors.
  2. Quality assurance. Quality assurance is all about patient safety, customer satisfaction, and improving healthcare quality. Quality control groups comb through incident reports to look for indicators that suggest a patient received high-quality, patient-centered care at a reasonable price.
  3. Educational tools. Incident reports make great training tools because everyone has an innate ability to learn from their mistakes — or the mistakes of others. Healthcare teams often use resolved incident reports as educational tools to prevent similar occurrences.

Be aware that because incident reports could potentially be used for legal purposes, providing incomplete, inaccurate, or false documentation in an incident report can harm patients and jeopardize the defense of any case — including your own.

What Classifies as an ‘Incident’ That Would Prompt a Report?

In most circumstances, nurses are required to complete an incident report whenever they witness a reportable event or are notified that one has occurred. What constitutes a reportable event may vary by organization and practice setting, but the New York State Department of Health has identified some of the most common types: