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