Administrative Safety Incident Reporting

1. Overview

This guide focuses on documenting events outside routine patient care: the Incident Report (or Occurrence Report). This is a tool for risk management and quality improvement, not punishment.

2. The Incident Report

Purpose

• Primary Goal: Quality improvement and preventing future reoccurrences.
• Culture: Moves from "Blame Culture" (Who messed up?) to "Just Culture" (What system failed?).

When to File

• Patient falls (with or without injury).
• Medication errors (including near misses).
• Needlestick injuries.
• Loss of property.
• Visitor injuries.

How to Write (The F.A.C.T. Model)

• F - Factual: Only what you saw/heard. No opinions.
• A - Accurate: Precise details (time, location).
• C - Complete: Full picture of event and immediate actions taken.
• T - Timely: Completed immediately while memory is fresh.

3. Critical Distinction: Incident Report vs. Medical Record

⭐ High-Yield Concept:

• The Incident Report: Internal, confidential, administrative. NEVER file or mention this in the patient's chart.
• The Medical Record: Legal record of patient care.

Example: Patient Fall

1. In Medical Record: Document the objective facts ("Patient found on floor... Vitals taken... Dr. notified").
2. In Incident Report: Document the facts PLUS internal details for review.
3. NEVER write "Incident report filed" in the medical record. This makes the internal report discoverable in a lawsuit.

4. Root Cause Analysis (RCA)

RCA is the process of finding the underlying system cause of an error.

The "5 Whys" Technique: Repeatedly asking "Why?" helps move from the superficial cause (MA gave wrong pill) to the root cause (Look-alike pills were stored next to each other).