An incident report system can be used to identify and report patient- and visitor-related occurrences. Health professionals and other clinic staff must complete an incident report for any patient or visitor who, while within the clinic and/or on the premises, is involved in an incident that has caused or has the potential to cause injury or loss or damage to his or her personal property. This includes incidents where the possibility of injury existed although no injury actually incurred and incidents that are inconsistent with the routine care of a particular patient or routine operation of the clinic.
All health professionals should be familiar with the clinic's incident-reporting procedures. A clinic should develop policies and procedures for incident reports, reviewed by counsel, that might include the following for incidents involving patients and incidents involving a medical device.
The person completing the incident-report form should be the individual who witnessed, first discovered, or is most familiar with the incident.
The form should be immediately presented to the reporter's supervisor, who must then investigate and recommend corrective action.
Description of the incident should be a brief objective description of the facts; it should not include the reporter’s judgment as to the cause of the event.
Quotes should be used, where applicable, with unwitnessed incidents (e.g., “Patient states ‘…’”).
Names of any witnesses should be included; name of the employee directly involved in the incident can be recorded in the witness space as well, if the employee is not the reporter.
The patient must be examined by an appropriate health professional, who should complete the appropriate section of the form pertaining to his or her findings.
The form should be completed no later than the end of the shift during which the incident occurred or was discovered to have occurred and should be forwarded to the clinic's administration within 24 to 48 hours.
The form is an administrative document, not part of the medical record. The fact that an incident-report form has been completed should not be reflected in the medical record, nor should the report be placed in the medical record.
Report the incident to the dental director or clinic administrator.
Fill out a device incident report form.
Record the manufacturer, model number, serial number, and control number of the equipment on the form.
Save the original packing if possible.
When equipment is involved, impound the equipment, the disposable product used with the equipment, and the packaging materials from the disposable product.
Tag the equipment with a sign that states "EQUIPMENT BROKEN—DO NOT USE."
Examples of Reportable Incidents
Error in the care of patients (e.g., errors in administration of medications, mistreatment).
Slips or falls in the clinic or on clinic grounds.
Development of conditions seemingly unrelated to the condition for which the patient was treated.
Adverse or suspected adverse reactions to a procedure or medication.
Appoint a staff member, preferably someone with clinical training, to receive and review all incident reports. In any case where there was an adverse outcome or the potential for an adverse outcome, fully investigate the incident. Incident-report forms and other significant incidents should be reviewed on an ongoing basis.
The review process allows for:
Identifying and documenting trends that might affect policies or procedures.
Recognizing and identifying clinic-wide programs to correct identified problems.
Assessing conformance to required standards of practice and care.
If trends develop in the occurrence of adverse incidents, then a root-cause analysis should be performed. This means looking not only at the activities that immediately led up to the incident but also at the systems and procedures in place surrounding the incident. Faulty systems and procedures, rather than health professional or staff competence, place health professionals and staff in positions where errors are more likely to occur.
This material includes general guidelines. The laws of each state may vary, and the reader may want to contemplate seeking legal advice from an attorney licensed in the state the health care provider practices for specific guidance.