Even with healthcare providers taking every possible measure to mitigate them, incidents are bound to happen. In high-income countries, it’s estimated one in ten patients experiences an adverse event in the hospital. No matter the cause, actions taken after the event are key and usually includes filling out a medical incident report (MIR). Creating incident reports using structured templates is essential to ensure all essential details are captured efficiently and accurately.
When completed correctly, MIRs serve as a formality that helps healthcare teams maintain consistency in care and resolution. Factual accuracy is critical when completing MIRs to maintain professionalism and clarity.
In this blog we cover:
An incident report is a form used to document and communicate an error or accident.
An MIR is a more specific type of incident report used in healthcare settings, such as clinics, hospitals, or transportation units. MIRs are used for both emergency and non-emergency events, with different protocols and policies for each type.
MIRs are used to document unexpected events and ensure all fundamental information is recorded. The MIR is an essential part of coordinating medical care, helping teams allocate resources properly and ensuring patients receive the best treatment possible for their situation.
This formal document can be used for any unexpected accident or event that may result in injury to the patient, such as a fall, medication event, testing error, security breaches or incidents involving workplace violence, or even patient self-injury.
Completed MIRs should be stored for future reference to support ongoing care and analysis.
When multiple incident reports are documented for the same setting or patient, they become part of an incident log. The log acts as a diary of events, chronologically listed, to help providers see the history of accidents or errors for a set time period.
Incident documentation in logs supports a systematic approach to tracking events, ensuring that each occurrence is recorded consistently and thoroughly for effective analysis and compliance.
Incident logs may be structured differently across different organizations to meet their unique needs.
The primary purpose of an MIR is to document what happened. It guides observers in capturing all the relevant details while they can still recall them accurately. Gathering all relevant information is essential when documenting an incident to ensure accuracy and completeness. Incident reports create a structured approach to explaining the who, what, when, and where of the injuries and damage, along with the actions taken after the fact.
The MIR can help in investigations of how or why the accident occurred, so it becomes crucial in getting to the root of single incidents, as well as larger care trends. MIRs include key components that support risk mitigation by ensuring all necessary details are captured for analysis and future prevention. The information gathered from a report can also become the basis for future training programs to address policy violations or overall care quality.
Incident reports and logs support healthcare teams as they address each individual incident, but they can also accomplish the following:
In addition, a “violence” incident log is a specific type of log that helps teams monitor, analyze, and reduce episodes of aggression or physical threats against staff and patients. It can be useful in measuring threats from an individual patient or in the patient population overall.
Incident report forms are the backbone of effective incident reporting in any organization. These forms provide a structured format for capturing all the crucial details when an incident occurs, ensuring that nothing important is overlooked. A well-designed incident report form prompts users to record specific information such as the date, time, and location of the incident, as well as the people involved and any witness statements. Including sections for a detailed incident description and contributing factors helps create a clear picture of what happened and why.
By standardizing the way incidents are documented, incident report forms make it easier to compare reports, identify patterns, and ensure consistency across the organization. This structured approach not only supports thorough documentation but also enhances workplace safety by making it easier to spot risks and prevent future incidents. Whether used in healthcare, construction, or office environments, effective incident report forms are essential tools for capturing crucial details, supporting compliance, and fostering a culture of safety.
Each healthcare setting will have a different reporting process for different categories of reporting. They may vary based on the requirements of the Occupational Safety and Health Administration (OSHA) Reporting and Fraud, Waste, and Abuse (FWA) Reporting guidelines. When writing reports, it is important to focus on ensuring compliance with all relevant regulatory requirements to maintain patient safety and meet legal obligations.
Questions to ask when determining each reporting method may include:
To ensure accuracy, always double-check details with multiple sources before submitting a report.
Because a report can be filled out according to any number of predetermined guidelines, teams should be familiar with how to handle each possible incident. Then, they should practice going through the procedures for each, including knowing who to report it to within their team or department. Staff should avoid speculation, blame and personal opinions in their reports to maintain objectivity and credibility.
Writing an incident report is essential for documenting workplace hazards, security issues, sentinel events, or natural disasters. It is important to include specific details and critical information to ensure the report is comprehensive and supports effective investigation and prevention.
To learn how to write a report about an incident, follow this step-by-step approach. For reference, we’ve also included a sample example of an incident report below to help you prepare.
To ensure a comprehensive keyword report, it is essential to document incidents thoroughly, capturing all relevant information for future reference.
The incident log should cover all the info needed to determine the “who, what, when, and where” of the incident.
An incident log should contain the following:
Including factual details and avoiding personal conjecture or opinion in your report is crucial to maintain objectivity and credibility. This also helps provide a reliable record for any future investigation or review. Finally, the existence of video footage of the incident should be noted in the MIR.
If using approximate instead of exact time, explain why.
Photograph the room or environment if safe and appropriate, according to your company’s internal policies.
Use objective medical language and avoid subjective assessments or speculation.
An incident report should be completed when you are able to reach those involved with the event, if not right away. For each of the people who saw or heard the incident, include:
All witnesses should sign and date the statement.
A security guard may be involved in documenting security or sentinel events, especially when their observations or actions are critical to the incident report.
Refer to the taxonomy for your organization for any codes, classifications, or abbreviations. If your team uses a comprehensive MIR template, make sure it’s updated with the most recent codes.
Please note, facilities often employ a security incident log template to document breaches, thefts, or unauthorized access efficiently and in alignment with regulatory guidelines. These are slightly different incidents from what are recorded on a medical incident log, but they still may be relevant to patient care and required by law to be documented.
This part of the form may take the most time and has the most opportunity for error since it’s not standardized. Try to include:
Also, this is not the time to assign blame, even when updating a violent incident log. Use active voice (“patient collided with a door”) instead of passive voice (“patient was hit by door.”) When possible, refer to proper medical terminology and don’t use defensive or judgmental words. This is not the time to analyze; just report the facts of what happened.
A thorough investigation is necessary to identify all contributing factors, including underlying causes that may not be immediately apparent.
If the incident didn’t result in an identifiable injury, state this.
When considering what information should be documented in an incident log, think about how visual aids can tell more of the story. Photos and video help stand in when words don’t accurately describe the incident. They can also speed up the documentation process and reduce reporting errors.
Include:
Follow policy for patient privacy and the privacy of those in the room, such as visitors, children, or staff. When and if possible, include a timestamp with all photos.
List actions in order of when they happened, and include both successful and unsuccessful interventions. If following a specific protocol, mention it in the report.
These actions are designed to enhance safety and prevent recurrence of similar incidents.
Whoever fills out the report and ultimately takes responsibility for it should include the following:
Use proper procedure for signature, whether it’s electronic or on paper. Only allow the actual reporter to sign, not a proxy.
The MIR is just part of the documentation done after an accident or injury. Other forms that can be added to the incident log may include:
Follow your organization’s rules for handling and storing the different types of documents. While an incident report may go inside the patient’s medical record, insurance notifications or insurance claims may not.
Others, including supervisors or regulatory agencies, may read any documentation, so write and store with this in mind. Some safety events require you to report to outside agencies, so be aware of what these are ahead of time.
It is important to keep all documentation, including the final approved report, accessible for future reference.
Taking corrective actions is a fundamental part of the incident reporting process. When an incident occurs, it’s not enough to simply document what happened—organizations must also analyze the incident reports to identify root causes and implement corrective measures. These actions might include updating procedures, providing additional training, or introducing new safety measures to prevent similar incidents from happening again.
Effective incident reporting enables organizations to spot trends and recurring issues, making it possible to address underlying problems rather than just treating symptoms. By systematically reviewing incident reports, teams can develop targeted corrective actions that improve workplace safety and reduce the risk of future incidents. This proactive approach not only helps prevent similar incidents but also demonstrates a commitment to continuous improvement and a safer work environment for everyone.
Follow-up is a critical step in the incident reporting process that ensures incidents are thoroughly addressed and corrective actions are effective. After an incident occurs, it’s important to reconnect with the people involved—including witnesses—to gather any additional information and verify that all necessary steps have been taken. This process can also uncover near misses or related incidents that might otherwise go unreported.
Incorporating follow-up into incident reporting helps organizations confirm that corrective actions are working and identify any gaps in the reporting process itself. By prioritizing follow-up, organizations reinforce their commitment to workplace safety, support effective incident reporting, and create opportunities for ongoing improvement. Regular follow-up not only helps prevent future incidents but also builds trust among staff by showing that every report is taken seriously and acted upon.
While proper documentation of incidents is a best practice and may be legally required in some cases, these documents can and will be used against a healthcare provider if they are produced in the event of a lawsuit. All reports should be completed with the understanding that in the event of a lawsuit, a highly capable plaintiff lawyer will ultimately have it and use it to question and cross-examine everyone involved. If possible, direct all completed incident reports to general counsel for their guidance and mark them “attorney-client privileged”.
This will give you the best chance to ensure they remain confidential and do not have to be produced in the event of a lawsuit. Although it is important to follow sound, ethical reporting standards, be sure to use good judgment in your documentation. Again, stick to the facts and avoid subjective commentary or blame so that any report remains factual and neutral in the event of a lawsuit.
It’s also important to know which reports written as part of a peer review process should be reported to the National Practitioner Data Bank (NPDB). Routine incident reports are not typically NPDB-reportable, but formal peer review actions affecting privileges are reportable.
Any reports made could become discoverable in litigation, especially if written as part of the regular course of business. Each state has its own protections for health care providers; however, some states give broader protections to documents relating to process improvements.
Reports are designed to capture detail around an incident, including the personnel involved and any injuries to the patient. By nature, they make it easy to discern what happened and, eventually, who was at fault.
Studies show that disclosing medical errors to the patient can reduce overall liability, as it creates a sense of trust between patient and provider. This can keep problems out of court and may even prevent a medical malpractice claim being made.
It’s also important to remember that it’s not just what you do say in an Incident report that can create liability but also what you do not say. Incomplete, inaccurate, or unreliable medical documentation is an issue in 10-20% of malpractice suits, making it difficult for physicians to defend themselves. Failing to add important information to a report can make it seem that proper treatment wasn’t administered or that negligence took place.
The MIR isn’t the only factor in determining liability during a malpractice suit, but by following wise documentation strategies, you can mitigate additional risk.
Most importantly, never alter reports after the sign or submission date without using proper amendment or addendum procedures. Courts may interpret altered records as a cover-up for something wrong even if the alteration was done with the best of motives. There are cases where an improperly completed alteration to the chart/report can lead to the judge to give the jury and “adverse inference” charge.
An adverse inference from a record alteration is a legal conclusion drawn by a court or jury that the missing or altered evidence would have been unfavorable to the party responsible for its modification. This inference, which stems from the legal principle of “spoliation of evidence,” functions to punish wrongdoers and discourage tampering with evidence.modification.Not only may such an instruction lead to a lost case, but it could result in higher damages, disciplinary action, and loss of reputation to your practice.
Implementing a robust incident reporting system brings significant benefits to organizations of all sizes. Effective incident reporting enhances patient safety by providing a clear record of incidents and also assists providers in identifying risks and preventing future incidents. It also supports compliance with regulatory requirements, helping organizations avoid penalties and maintain high standards of care.
Despite its importance, incident reporting can present several challenges for organizations. Ensuring that incidents are reported promptly and accurately can be difficult, especially in fast-paced or high-pressure environments. Collecting and analyzing incident reports requires time, attention to detail, and sometimes specialized skills to interpret complex data.
Maintaining the confidentiality and security of incident reports is also crucial, as these documents often contain sensitive information about people involved and the circumstances of the incident. Cultural and language differences can further complicate the reporting process, potentially leading to incomplete or inaccurate documentation. Additionally, the process of documenting incidents and conducting thorough investigations can be resource-intensive.
By recognizing these challenges, organizations can take steps to improve their incident reporting systems—such as providing training, simplifying report forms, and fostering an open culture where staff feel comfortable reporting incidents. Overcoming these obstacles is essential for ensuring effective incident reporting, supporting workplace safety, and achieving organizational goals.
As patient records have moved almost entirely to digital formats, so have clinical and hospital administrative forms. Many of the top medical records software providers have added incident reports and logs to their functionality, so documentation, storage, and filing aren’t a complicated, manual step. Digital tools also streamline the process of creating incident reports, making it easier for staff to document unexpected events efficiently and thoroughly.
Providers should be free to choose the Incident Reporting System (IRS) that fits their needs and works well with existing processes, as long as it meets state and federal guidelines for their type and standard of care. Software solutions often support a systematic approach to incident documentation, ensuring compliance and consistency across the organization.
Use this free medical incident report template to get started.
While forms can become documentation trails to be used in litigation, the original purpose of the MIR was to improve patient care. Their potential to highlight systemic issues has become more well-known in recent years, thanks to the advancement of AI. Effective incident documentation supports ongoing process improvement by ensuring that safety events are recorded in a structured and consistent manner.
Consider this example: A hospital department analyzed its incident forms and found a sharp uptick in needle sticks. Upon investigation, they found waste containers for sharps were too far from where the staff uses the needles. Further, forcing them to walk long distances to throw needles away increased the odds of sticking someone along the way.
Each incident, on its own, may not seem extraordinary. When taken in context of all incidents, there’s a pattern. This makes reporting forms potentially valuable when used as part of process improvement and training programs. Keeping incident reports accessible for future reference ensures that organizations can continually learn from past events and enhance safety practices.
A medical incident report isn’t something to be afraid of. Ensure your practice is protected by exploring Indigo malpractice insurance, and get malpractice coverage tailored to healthcare professionals today.
Image by vm from iStock.
