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Reporting an Incident

A nurse assistant walks into a patient’s room and finds that the patient has fallen in the bathroom. The patient insists that she is not hurt, but the CNA must still report the incident because anything unusual that happens to a person receiving care must be documented.

Incident reports are required for several reasons. First, symptoms might not always be immediately evident when an accident or injury occurs. The patient who fell in the bathroom, for example, might later develop a large bruise, and other members of the team need to know what happened to cause the bruise. Second, care facilities try to improve safety on a continuous basis, and understanding how a patient received an injury could result in safer practices. Lastly, if a patient is becoming injured by performing certain tasks, an incident report might guide any corrective action that is taken. For example, the patient’s care plan could be changed to try to prevent future injuries.

Incidents are usually reported in two ways: verbal and written. You should always tell a nurse or supervisor whenever an incident occurs. Additionally, you will need to learn how to complete a written incident report. When reporting the incident, provide facts rather than opinions. Even if you suspect someone or something is to blame for the incident, focus on what happened rather than why it happened. Do not omit any details. You should always report all incidents as soon as you can while the details are fresh in your mind.

In your incident report, try to answer the following questions:

  • Who was involved in the incident? Give the names of patients involved and also any witnesses.

  • What happened to the person involved?

  • Where and when did the incident occur?

  • Did anyone give assistance or first aid? If so, what assistance was given and by whom?

Reporting incidents completely and in a timely manner will help to keep all members of the care team informed and will create a safer environment for everyone.

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© 2015 by Southwest Adult Basic Education

Project made financially possible through grants from:

Southwest Initiative Foundation, Marshall Community Foundation, Southwest Regional Transition Partners, Southwest Adult Basic Education, Marshall Healthcare Partners