Incident Report - ANSWER accurate and comprehensive report used by healthcare
agencies to document any unexpected or unplanned occurrence that affects or could
potentially affect a patient, family, or staff
Examples - ANSWER medication errors, falls, patient injury such as burns, medical-
legal incident such as patient or family refuses treatment as ordered and refuses to sign
consent, incorrect sponge count in surgery, failure to report change in patient's condition
Document - ANSWER -complete name of the person or people involved and the names
of all witnesses
-complete factual account of the incident
-any equipment or resources being used
-any variables believed to be important
-in detail the patient's response and the treatment
Avoid - ANSWER -including a reference to the incident report
-using words such as error or inappropriate
-using inflammatory words or judgmental statements