Why is incident reporting important for healthcare organizations?

A healthcare incident or adverse event is an unfavorable event (e.g., a medical error, patient injury, or equipment failure) that harms a patient, caregiver, or other individuals—or has the potential to harm them.

But why is it so important to report healthcare incidents?
Incident reporting in healthcare refers to collecting healthcare incident data with the goal to improve patient safety and care quality. Done well, it identifies safety hazards and guides the development of interventions to mitigate risks, thereby reducing harm.

Incident reports help staff identify and change the individual or system-level factors contributing to medical errors. Medical staff—such as nurse managers, front-line nurses, pharmacists, or physicians—who are directly involved in or observe the adverse event or the actions leading up to it typically submit the majority of incident reports. (According to The Joint Commis­sion in the United States, nurses submit the highest number of incident reports.) But ideally, your organization has a mechanism for anyone—staff, patient, family, or visitor—to report an incident.

At the organizational level, incident reporting can foster internal transparency and cultivate a continuous improvement culture when encouraged by nurse managers and other leaders.

How reporting benefits individual staff members

When encouraging your workforce to report incidents and events, of course it’s important to highlight at a high level how the process improves patient-care quality and the safety of all healthcare participants. After all, those are among the primary goals of every healthcare organization.

But you may be missing out on opportunities to communicate some of the more subtle reasons to encourage reporting of healthcare incidents. The majority of clinicians and healthcare staff want to learn and readily accept instruction on ways to improve. That’s true whether an incident involved them, a coworker in their department, or a staff member in another part of the organization. The caveat is that event reporting and subsequent learnings must be fostered in a blame- and shame-free environment.

In onboarding and training, share with staff the professional benefits of incident reporting, such as the following:

• Reporting provides input for discussion with senior staff about unsafe situations and shows that the staff member is alert to continuous improvement efforts, which will reflect positively in reviews and compensation discussions
• Incident reporting demonstrates a commitment by the individual staff member to put patient-centered or person-centered care first, rather than simply following protocols
• Ongoing training in safety and risk mitigation is required of many healthcare professionals for licensure and certification. There is no place better to demonstrate their attention to improvement than at the personal and team levels
• Those who are closest to the bedside and interact with patients the most often have the best insight into whether processes are actually working. Staff who speak up when they see unsafe conditions or inefficiencies pave the way to improved work conditions for the individual and their colleagues
• Staff are often in the best position to identify and report incidents that result from over-burdensome workloads, scheduling failures, and other workforce management issues that can be corrected to benefit all
• Healthcare staff—and clinicians who work as part of a patient-centered healthcare team in particular—are mutually responsible for the care provided to a patient. The work of one reflects the work of all, and reporting incidents and events is the right thing to do
• Developing a habit to report an incident directly after an event happened ensures that the individual “gets it right,” while the details are still fresh, and therefore has the most impact

How reporting benefits managers and the organization

Incident reporting improves patient safety and care quality at the enterprise, facility/site, and departmental levels as well. Some of the primary benefits include the following:

It improves safety for all healthcare participants: The number-one reason to encourage incident reporting is to ensure that the many positive contributions of your organization at the patient, facility, and community levels are not overshadowed by a safety breach. It’s imperative to do everything possible to protect every patient, staff member, visitor, vendor, or any other individual who walks through your doors or does business with the organization virtually.

It helps identify root causes: All healthcare incidents have a cause. The root causes must be identified—and corrected—to try to prevent adverse events from recurring. A patient incident report is a detailed, written account of the chain of events leading up to an adverse event. The root cause(s), such as communication problems, inconsistent procedures, or inadequate staffing, lies somewhere in that chain of events. Incident management software analyzes the causes of each incident. Correcting or avoiding the deficiency can help eliminate the undesirable consequence from recurring.

It hones policies and procedures: By increasing transparency, incident reporting sheds light on factors that contribute to errors and adverse events, such as:

• Unsafe situations (e.g., spills that aren’t cleaned up immediately)
• Insufficient training of new staff
• Incorrect or unclear protocols or procedures (e.g., for medication administration)
• Excessive workload due to scheduling gaps and/or understaffing (leading to exhaustion that contributes to medication and other errors)
• Correcting faulty protocols, policies, and procedures is essential for improving patient and staff safety.

It improves clinical risk management: Incident reports are essential data points for clinical risk management. Hospital administrators must know their organization’s safety performance and be able to identify preventable issues that increase their risk exposure. Assessing clinical risks allows hospitals to provide high-quality care and a safe working environment for all staff.

It helps facilitate continuous quality improvement: Hospitals focus on improving patient safety and care quality by continuously evaluating and improving their clinical processes and other patient-related operations (e.g., admission and discharge procedures). Incident reporting identifies potential areas of quality improvement and helps the organization succeed in its clinical quality improvement efforts.

It can promote continuous learning: Using resolved patient incident reports as case studies or in staff training documents and live sessions helps prepare your healthcare workforce for real situations. Staff who learn from their own or others’ mistakes can better prevent more incidents from occurring.

It captures useful data for big-picture analysis: Managers must continuously report statistics and aggregated data to administrators and/or the board. The more data there is about quality and safety, the better—and incident reporting management dashboards can help. The collection of data on incidents, complaints, and via checklists is just the first step toward improving quality and safety. The next step is analyzing the data and informing the organization through reports and dashboards to discover trends, prioritize risks, and monitor key performance indicators.

It can help reduce costs: Gaps in staff scheduling that delay care and jeopardize the safety and draw fines and penalties for non-compliance with governmental or sector regulations. Often, errors result in costly legal suits and bad press. All of these are negative outcomes that may have started with a single incident. Encouraging staff to stay on top of risk mitigation through incident reporting is a proven way to help reduce unnecessary costs.

Barriers to incident reporting

Under-reporting of adverse events and medical errors is common. Public health researchers estimate that only 10-20% of errors are ever reported and of those, 90-95% cause no harm to patients. Therefore, the adverse events that do harm patients are not being reported and examined. Under-reporting may be due to several common barriers to incident reporting.

Assess the potential barriers to reporting in your organization on a regular basis, beginning with the examples below:

1. Worry over legal ramifications
2. Blame and shame culture, guilt, fear of punishment
3. A lack of time to report
4. No easy reporting system
5. No trust in follow-up/repeated reports with no follow-up
6. Already reported the same event in the past
7. Details are lost with time
8. Lack of encouragement from administration and/or colleagues

>> Learn more about these hurdles in our blog “Barriers to incident reporting in healthcare”.

Incident reporting best practices in healthcare

The healthcare professional who witnessed the event—or the first staff member who was notified about it—should file the report.

File an incident report whenever an unexpected event occurs

The incident report is required any time:

• A patient makes a complaint
• A medication error occurs
• A medical device malfunctions
• Anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury

Complete the incident report as soon as possible, while the details are still fresh, but no more than 24-48 hours after the incident occurred.

Just the facts

who, what, where, when, and how: Incident reports should describe what happened, answering key questions. Incident reporting needs may vary by organization, but this basic information is generally required:

• Patient name, date of birth, and hospital ID number
• Names of any other affected individuals (e.g., staff or visitors)
• Date, time, and location of the incident
• Name and address of the facility where the event occurred
• Type of incident (e.g., medication error, fall, equipment failure)
• Brief, factual description of the incident, written in chronological order
• Witness name(s) and contact information
• Details and total cost of the injury and/or damage, if any
• Action taken at the time
• Name of the physician who was notified
• Name and contact information of the person reporting the incident (if appropriate)

Write objectively

Incident reports should focus on the facts, detailing direct observations, actions taken, the assistance provided, and communications initiated:

• Describe exactly what you saw when you arrived on the scene or what you heard that led you to believe an incident had taken place. When possible, include direct quotes from the patient and/or other involved parties (e.g., a colleague or visitor) and clearly identify the source.
• Add other relevant details, such as your immediate response (e.g., calling for help and notifying the patient’s physician). Include any statement(s) a patient makes that may help to clarify his state of mind.
• Avoid making assumptions. Do not draw conclusions about how the event unfolded or speculate about who or what may have caused the incident.
• Do not assign blame. Do not point a finger at a colleague. The incident report should be a detailed description of what happened, not whom you think is responsible.

Use incident management software

Despite the availability of incident reporting systems, many healthcare organizations still rely on manual, paper-based incident reporting, often using hand-written reports. Manual incident reporting is a time-consuming, costly, error-prone process that has many limitations, including low-quality data and limited flexibility.

Collecting incident data is just the first step in the incident management process. To identify and correct safety problems, the right people have to be able to access, sort, organize and analyze that incident data, something that is very challenging—if not impossible—when using paper reports.

To take full advantage of incident reporting, use incident management software that collects incident data electronically, stores that data in a central database, and analyzes it using proven methods.

More information about incident reporting

• Download our eBook "Blueprints for reporting forms" if you want to know more about developing your own reporting forms.
• Our special topic page will discuss the main points concerning the organization of incident management

SaaS software solutions for incident reporting:

• Incident Manager solution page
• Incident Manager product sheet
• Application overview for 5 different types of healthcare incidents

Or learn more in one of our blogs:

• The pitfalls of quality registrations on paper or spreadsheets
• The financial impact of patient safety errors
• Make healthcare safer with system-wide incident reporting