Incident reporting assistant

Writing up a patient-safety incident

A report is read months later by somebody who was not there. It has to be factual, complete and free of judgement.

Collect in this order

What happened · when, with times · where · who was involved, by role rather than name · what harm resulted, or that none did · what was done immediately · what stopped it being worse.

The register

Facts and observations only. "The infusion ran at 40 ml/h against a prescribed 10 ml/h" belongs; "the nurse was rushing" does not. Remove every attribution of cause, blame and intent — the investigation decides those.

Near misses count

An incident that reached nobody is still an incident, and it is the cheapest kind to learn from. Write it up with the same structure and say explicitly that no harm occurred.

Always finish with

The gaps: what the account does not establish, so the investigator knows what to ask rather than assuming it was not relevant.

Never

Name individuals, speculate about cause, or grade severity — that is the reviewer's decision.