Incident Reporting in the Workplace

CPDTime.
11m

Published: 30 August 2022

Incident reporting is an accountability of all staff working in healthcare facilities.

Knowing how to fill out an incident report is necessary knowledge for any professional. An incident report should be completed immediately after an incident has occurred and appropriate corrective action followed.

Incident reports are integral to a functional healthcare system that is committed to ongoing improvement and transparency.

The following is intended as a general guide to filling out an incident report. Your organisation may have certain criteria involved in completing an incident report and it is advised that you make yourself aware of the appropriate policies specific to your facility.

Incident reporting relates to the following Australian healthcare standards:

What is an Incident?

An incident is anything that happens out of the ordinary in a facility. Specifically, unplanned events or situations that result in, or have the potential to result in injury, ill health, damage or loss (WorkSafe Tasmania 2022).

Examples of an incident in healthcare:

  • An aged care resident slips and falls on their way to the bathroom.
  • A patient is accidentally dispensed a medication prescribed for another person.

Types of Incidents

Clinical incidents

The Australian Commission on Safety and Quality in Health Care (2021) defines a clinical incident as ‘an event or circumstance that resulted, or could have resulted, in’:

  • Unintended or unnecessary harm to a patient or consumer
  • A complaint, loss or damage, and/or
  • A near miss.

This may include an omission of care that would have likely benefited the patient or consumer (ACSQHC 2021).

Clinical incidents could involve:

  • Communication-related incidents
  • Diagnosis-related incidents
  • Falls and other injuries
  • Medication errors
  • Pressure ulcers
  • Treatment issues
  • Healthcare-associated infection
  • Privacy breaches.

(Hooiveld 2022; Benalla Health 2011; Australian Digital Health Agency 2022)

client sitting alone in room

Sentinel events

Sentinel events are a subtype of clinical incidents that are considered the most serious incidents. They are entirely preventable incidents that result in the serious harm to or death of a patient (ACSQHC 2020).

There are 10 nationally-recognised sentinel events in Australia. They are:

  1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
  2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
  3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
  4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
  5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
  6. Suspected suicide of a patient within an acute psychiatric/ unit or acute psychiatric ward
  7. Medication error resulting in serious harm or death
  8. Use of physical or mechanical restraint resulting in serious harm or death
  9. Discharge or release of a child to an unauthorised person
  10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death.

(ACSQHC 2020)

Non-clinical incidents

Examples include:

  • Bullying
  • Hazards being identified
  • Injury to staff member
  • Injury to students or visitors
  • Professional misconduct
  • Property issues
  • Security issues or breaches
  • Vehicle accidents.

(Benalla Health 2011)

Take into consideration the above examples as well as other issues as outlined by your organisation.

What are Your Responsibilities?

Sentinel events

Healthcare services must report all sentinel events that occur via their state or territory’s incident reporting system (SCV 2022).

Reportable Incidents in Aged Care

Under the Serious Incident Response Scheme (SIRS) introduced in 2021, aged care providers are required to report eight types of incidents to the Aged Care Quality and Safety Commission:

  1. Unreasonable use of force
  2. Unlawful sexual contact or inappropriate sexual conduct
  3. Neglect
  4. Psychological or emotional abuse
  5. Unexpected death/
  6. Stealing or financial coercion by a staff member
  7. Inappropriate use of restrictive practices
  8. Unexplained absence from care.

(ACQSC 2022)

For more information on the SIRS, see Ausmed’s Training Module: Serious Incident Response Scheme (SIRS).

Immediate Actions to Take Following an Incident

Once an incident has been identified, you must:

  • Ensure the safety of the affected person(s)
  • Provide immediate care to the affected person(s) and ensure all necessary steps have been taken to support and treat them
  • Make the situation safe
  • Notify your manager and the medical team as necessary
  • Notify security and the police if necessary
  • Remove or address any malfunctioning equipment or supplies.

(ACSQHC 2021; SA Health 2017)

Once the situation has been made safe, document information regarding the care provided prior to and following the incident in a medical record. Ensure preventative measures are in place in anticipation of further injury. Inform a line manager and, if appropriate, preserve evidence in the surrounding area (SA Health 2017).

How to Write An Incident Report

writing incident report

An incident report requires questions relevant to who, what, when, where, how and why to be completed (Safe Work Australia 2015).

Who

  • The name and contact details of the person reporting the incident
  • The name and details of the person(s) affected.

What

  • What occurred
  • Type of incident (e.g. death, serious injury, illness)
  • In-depth description if the incident
  • What initial actions did you take?
  • Incident severity rating.

When

  • When did the incident occur? (date and time)

Where

  • Where did the incident occur?

How and why

  • How and why did the incident occur?
  • What were the contributing factors (i.e. events surrounding the incident)?

(Safe Work Australia 2015; NSWNMA 2020)

Considerations for completing a report

  • Use concise, objective language (void of opinion)
  • Be as specific as possible
  • Write what was witnessed and avoid assigning blame or making assumptions about what occurred
  • Avoid abbreviations
  • De-identify information where appropriate
  • Report the incident in a timely manner.

(NSWNMA 2020; ACSQHC 2021)

Who can submit an incident report?

Any staff member who witnesses an incident has an accountability to report it. Visitors, community members, students, contractors, patients/clients/residents and volunteers may also witness incidents and need to communicate this to the nominated person within the organisation they are in.

Local policies and procedures will guide who makes the actual written submission using the risk management tool or software provided by your organisation.

Is there a broader purpose for an incident report?

An incident report not only has the potential to shed light on a particular incident, but may reveal room for improvement in systems, procedures and environments.

In addition, an incident report:

  • Recognises that incidents often have contributing factors that are, for the most part, related to the systems of care, as opposed to the individual
  • May involve the reporting and management of an entire clinical team, leading to timely action and reduced risk
  • Puts the focus on quality improvement, creating a just and transparent culture, which includes support for the staff involved in the incident.

(SA Health 2017)

hazard water on ground

References


Test Your Knowledge

Question 1 of 3

Which one of the following is a non-clinical reportable incident?

Author

educator profile image
Ausmed View profile
Ausmed’s editorial team is committed to providing high-quality, well-researched and reputable education to our users, free of any commercial bias or conflict of interest. All education produced by Ausmed is developed in consultation with healthcare professionals and undergoes a rigorous review process to ensure the relevancy of all healthcare information and updates to changes in practice. If you have identified an issue with the education offered by Ausmed or wish to submit feedback to Ausmed's editorial team, please email ausmed@ausmed.com.au with your concerns.