Using Your Incident Report System as a Staff Training Tool

By Tom Ludwig, RN, MBA, FACMPE

Healthcare administrators are very familiar with incident reports and their role in risk management.  Did you know that incident reports can also be used as a staff training tool?

Incident reports are a critical part of managing risk in a practice.  They are a means of documenting unusual occurrences that happen during the course of patient care.  According to Stephen Frew, Risk and Compliance Consultant with Johnson Insurance Services, LLC, an unusual occurrence is defined as “those events that occur in your clinic, on your premises, or involving your staff or physicians that might or could cause loss, injury or upset to a patient or member of the public.”  In Incident Reports: A positive part of an effective risk management program, Kerri Gantt states, “Incident reports describe the facts of any situation that deviates from usual and customary processes and-or outcomes.”  Examples of occurrences that warrant an incident report include:

  • A patient slips and falls in your parking lot
  • Medical equipment malfunctions during the course of patient care
  • A family member expresses dissatisfaction with how an employee spoke to them

What information should an incident report contain?  Gantt recommends the following components:

  • Patient’s name
  • Diagnoses
  • Date and time of incidents
  • Description of the events
  • A list of equipment used for procedures
  • Physicians and staff involved in the incidents
  • Witnesses’ names

Once completed, incident reports should be sent to the organization’s risk manager (or equivalent person) for review within 24 hours of the occurrence.  The organization should then have a process in place to appropriately address each incident based on its level of severity and potential legal risk.

In using your incident report system as a training tool, select an incident that you feel presents an appropriate topic for discussion by a group of employees.  Types of incidents that usually provide material for a good teaching opportunity are communication-related – communication with patients or their family members, communication between staff or departments within the organization, or communication with other healthcare organizations or agencies.

When reviewing an incident with staff, prepare a handout that summarizes the details of the incident.  (In order to respect the privacy of patients or family members who were involved in the incident, the names of those people should be omitted from the summary.  You should also omit the names of any specific providers or staff involved in the incident.)  After reviewing the summary with staff, use an open discussion format to answer the following questions:

  • What are the key issues in this incident?
  • What did we do well in this incident?
  • What did we not do well?
  • What should we have done differently?

An important part of the discussion process with staff is that they understand that this is not an exercise to assign blame to an individual or department.  Rather, it focuses on improving the processes, services or facilities that support your providers and staff in the care they provide.  Once staff understand and accept this problem-solving philosophy, not only will you have rich discussions about how to improve your organization – staff will also be more likely to submit incident reports because of the positive environment in which they are viewed.


Tom Ludwig, RN, MBA, FACMPE is the President and CEO of Forward Healthcare Solutions LLC.    Efficiency in Practice is the free eNewsletter for medical practice managers who want to save time, money and reduce risk.  For more information and to access your FREE report, Patient Collections: It’s Make or Break for Many Practices, visit 


This article can be reprinted freely online, as long as the entire article and this resource box are included.

Comments are closed.