Incident Reporting &
Quality Improvement
How nurses document the unexpected, protect patients, and use data to make care safer over time.
What Is an Incident Report?
An incident report (also called an occurrence or variance report) is an internal document that records any event inconsistent with routine patient care or expected facility operations.
When Must You File One?
Connecting to Quality Improvement
Quality Improvement (QI) is the systematic process of analyzing data to improve patient outcomes. Incident reports are a primary data source that feeds the QI cycle.
The Core Rule
Objective Facts Only
An incident report records only what you observed and did. Avoid opinions, conclusions about cause, and blame.
| Write This | Not This | |
|---|---|---|
| Fall | "Found on floor beside bed." | "Patient fell because rails were down." |
| Error | "10 mg given; ordered dose 5 mg." | "Nurse was careless." |
| Outcome | "No visible injury noted." | "Patient is fine, no harm done." |
Near Miss vs. Sentinel Event
| Near Miss | Sentinel Event | |
|---|---|---|
| Reached patient? | No, caught in time | Yes |
| Harm | None | Death or serious harm |
| Example | Wrong dose flagged before giving | Surgery on wrong site |
| Response | Incident report | Report + Root Cause Analysis |
Step-by-Step Approach
Example 1: A Patient Fall
A nurse finds a patient sitting on the floor next to the bed. What is the first action?
Example 2: A Medication Error
A nurse realizes she gave \( 10 \text{ mg} \) of a drug ordered at \( 5 \text{ mg} \). The patient appears stable. What now?
Example 3: Using the Data
A unit logs 9 falls per month. After adding hourly rounding, falls drop to 3 per month. What is the percent reduction?
Common Mistakes
Summary Comparison
| Medical Record | Incident Report | |
|---|---|---|
| Purpose | Document patient care | Risk management & QI |
| Legal record? | Yes, part of chart | No, internal only |
| Mention each other? | Never names report | Never copied to chart |
| Tone | Objective facts | Objective facts |
| Goal | Continuity of care | Improve the system |
Key Takeaways
Question 1 of 5
A nurse finds a patient on the floor. What is the first action?
Question 2 of 5
Which statement about the incident report is correct?
Question 3 of 5
A nurse catches a wrong dose before giving it. This is an example of a:
Question 4 of 5
Which entry is the most appropriate for the medical record after a fall?
Question 5 of 5
A unit's monthly falls dropped from \( 8 \) to \( 2 \) after a new protocol. What is the percent reduction?
You're Ready
Report honestly, document objectively, protect patients, and let the data drive safer care.