Incident Report Writing in Nursing Example [Edit & Download]

Header Information
Date: February 12, 2025
Time: 7:45 AM
Location: Ward 5, St. Mary’s Hospital
Reported by: Amanda Green, Registered Nurse

Description of the Incident
At approximately 7:30 AM, a fall incident occurred involving an elderly patient, Mr. George Thompson, in Ward 5 of St. Mary’s Hospital. Mr. Thompson, who is recovering from hip replacement surgery, attempted to walk unassisted to the bathroom and fell, as his walker was not within easy reach.

Parties Involved

• George Thompson: Patient, suffered minor injuries from the fall.
• Amanda Green: RN on duty who responded to the incident.
• Jessica Lee: Nursing Assistant assigned to assist Mr. Thompson.

Actions Taken
Immediately after the fall, the following actions were taken:

• Mr. Thompson was assisted back into his bed, and a preliminary assessment was conducted to check for injuries. He reported pain in his right arm.
• The on-call physician was alerted and arrived to examine Mr. Thompson, confirming a minor sprain in his right wrist.
• An incident report was initiated by Nurse Amanda Green, and all details of the event were documented, including witness statements and the initial health assessment.
• Mr. Thompson was provided with pain relief medication and comfort measures were applied.
• The family of Mr. Thompson was informed about the incident and the measures taken following the fall.

Recommendations for Future Prevention

1. Patient Mobility Assessment: Regular assessments of patients’ mobility and necessary adjustments to care plans to ensure safety aids like walkers are always accessible.
2. Staff Training on Fall Prevention: Continuous education and training for all nursing staff on fall prevention strategies and proper patient handling techniques.
3. Environmental Safety Checks: Routine checks to ensure that all patient areas are free of hazards that could lead to falls.
4. Patient and Family Education: Educating patients and their families on the importance of requesting assistance before attempting to move, especially post-surgery.
5. Review of Patient Care Equipment: Regular review and maintenance of patient care equipment to ensure they are in proper working condition and placed appropriately.

Attachments

• Medical Assessment Report: Document from the physician detailing Mr. Thompson’s condition post-fall.
• Witness Statements: Accounts from other staff and patients who were present at the time of the incident.
• Safety Audit Results: A follow-up report on the safety measures implemented in Ward 5 post-incident.
• Staff Training Records: Documentation of recent training sessions attended by the nursing staff related to patient safety and fall prevention.