Incident Reporting Policy: Essential Elements

Record what happened. The incident policy should state that a record of the incident should be written as soon as everyone is safe and out of harm’s way. Record what happened while it is fresh in everyone’s memory. Record what actions were taken to address the incident, what policies and procedures should be followed and what steps should be taken next.

Essential information to include is:

• The date, time and place of the incident
• Exactly what happened, as best remembered
• Names of any witnesses to the incident
• Staff’s response to the incident, including what steps they took
• Staff’s thoughts on what may have caused the incident, if possible

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For example, a resident’s medication went missing, and while the policy states that this will be brought to the attention of the director immediately, no one said anything for two weeks.  It was not until another person was looking at the medication records that they noticed the medication counts did not add up appropriately.  This is a potential hazardous situation where there is a risk to resident health or safety, because all medication should be accounted for according to the organization’s policy.

Once you notice this incident, you should record what happened.  What steps did you take to address the incident?  Did you talk to the staff involved? The resident? Find out what happened to the medication.  Did you adjust their recovery plan?  Did support the resident in talking with their treatment or medical care providers to adjust their medication?

Record what contributed to the incident.  Did this resident have many medications and it was easy to loose track of this one?  Is it that this medication was considered to “not be harmful” and so staff and the resident were not as careful?