Question

How to write an incident report that submitted to the nurse in charge? what components should be included?

Please take the following scenario as an example to formulate an incident report.

David, 4 months old boy, was admitted to the Paediatric ward of the Children's hospital 3 days ago because of diarrhea and stayed in Bed 2. You were the primary nurse of David and worked in afternoon shift today. David's health condition has improved and ready to be discharged home today i.e. 10 December 2019. You have informed David's mother on phone and she replied that she could come to pick David up after office hour. After the shift handover at 2:45 pm, you conducted patient round and noticed that David was not in his cot. His identity bracelet with security alarm tag was found on his bedside locker. Mother of Lucy, the patient next to David told you that she saw a tall lady in yellow dress had left the cubicle with David and his belongings 20 minutes ago. You have done the following actions Time 2:48pm 2:50pm action Inform ward in-charge. Perform local search in ward area. Contact hospital security staff for hospital search in parallel with David and the lady's description. Inform on call MO Dr. Chan TY and David's mother that David cannot be found Report to police. 2:55pm 3:00pm At 3:10 pm, you received a call from David's mother saying that, upon her request for help. her elder sister had brought David home already without informing ward staff. David, who appeared cheerful, was brought back to ward by his aunt at 3:30 pm. On call MO Dr. Chan TY examined him with no abnormality detected, police was informed. David was discharged home with his mother at 4 pm.

Answer 1

Incident report is a document which is prepared to record details of an unusual event that occurs at any healthcare facility. It contains exact details of the unusual occurrence which threatens patient's safety.

A good incident report must be clear, well-organized, complete and concise. It must be accurate, specific, factual and objective. Proper grammar, punctuation, spelling and abbreviations should be used in writing a good incident report. All the events should be mentioned in a chronological sequence. Direct quotations made by witnesses or the affected party should be mentioned. Writing of incident report should be started as early as possible so that key details of the events can be easily remembered. This is how we can write a good and effective incident report.

The components which should be included while writing a good incident report are :-

• Date, time, and location of the healthcare facility.
• Location of the incident at the healthcare facility.
• Type of incident.
• Names of the incident affected persons.
• Names of the witnesses and other involved persons.
• Events in the chronological sequence.
• Actions taken immediately after the occurrence of incident.
• Treatments provided.
• Other contributing factors related to the incident.
• Names of the persons who were notified and informed.
• Recommendations to prevent such similar future incidents.