Comprehensive Information to Include in an Incident Report for a Patient Found on the Floor
When completing an incident report for a patient found on the floor, you should document detailed information about the event, patient condition, and follow-up actions to ensure proper monitoring of patient safety incidents and facilitate system improvements. 1
Essential Components of the Incident Report
Patient Information
- Patient's full name, medical record number, age, and gender
- Current diagnosis and relevant medical conditions
- Mobility status and fall risk assessment score prior to the incident
- Mental status (orientation, confusion, sedation level)
- Medications that may contribute to falls (sedatives, hypnotics, antihypertensives)
Event Details
- Exact date and time of the incident
- Exact location where patient was found (room number, specific area)
- Position in which the patient was found
- Whether the event was witnessed or unwitnessed
- Time elapsed since the patient was last seen/checked
- Activity the patient was attempting when the fall occurred (if known)
- Use of assistive devices or restraints at the time of incident
- Bed/chair alarm status (on/off, functioning properly)
Environmental Factors
- Lighting conditions
- Floor conditions (wet, cluttered)
- Presence of obstacles or hazards
- Bed height and position
- Side rail positions (up/down)
- Call bell placement (within reach or not)
Patient Assessment Following the Incident
- Vital signs immediately after finding the patient
- Level of consciousness
- Presence of any injuries (bruising, lacerations, deformities)
- Pain assessment (location, severity)
- Neurological assessment
- Any changes from baseline condition
Immediate Actions Taken
- First aid or emergency care provided
- Notification of physician (name and time notified)
- Diagnostic tests ordered (x-rays, CT scans)
- Interventions implemented
- Changes to care plan made
Staff Information
- Names and roles of staff who discovered the patient
- Names and roles of staff who responded to the incident
- Staffing levels at the time of the incident
- Workload conditions at the time of the incident 1
Follow-up Actions
- Patient monitoring plan
- Family notification (who was notified and when)
- Changes to fall prevention plan
- Equipment needs or modifications
Reporting Best Practices
Use Electronic Reporting When Available
Electronic reporting systems have been shown to increase the reporting of patient safety incidents, reduce reporting time, and provide immediate accessibility to information for analysis 1. Computer-based reporting is gaining momentum over paper-based systems due to its effectiveness.
Focus on System Factors, Not Blame
The incident report should focus on organizational and communication problems rather than assigning blame to individuals. The system approach regards errors as opportunities to improve the system, not as human failures 1.
Be Objective and Factual
- Document only what was observed, not assumptions
- Use quotes when documenting patient statements
- Avoid judgmental language or placing blame
- Be specific and detailed in descriptions
Common Pitfalls to Avoid
- Incomplete documentation: Failing to include all relevant details about the incident
- Delayed reporting: Not completing the report promptly while details are fresh
- Focusing on blame: Emphasizing individual error rather than system factors
- Omitting context: Not documenting workload, staffing, or other contributing factors
- Lack of follow-up: Not documenting changes made to prevent recurrence
Critical Communication Requirements
Results suggesting the need for immediate or urgent interventions must be readily identifiable in the report and verbally communicated in real time through closed-loop communication to the appropriate healthcare providers 1.
Importance of Proper Incident Reporting
Proper incident reporting serves multiple purposes:
- Identifies system weaknesses that contribute to patient safety incidents 2
- Provides data for quality improvement initiatives
- Helps develop preventive strategies
- Supports a culture of safety and transparency
- Reduces the risk of similar incidents occurring in the future 3
Remember that incident reporting alone does not improve care quality; it's essential to identify the context in which the incident occurred and then identify appropriate solutions 1. The entire healthcare team should be actively involved in analyzing critical incidents through regular discussion to promote learning and system improvement 4.