Incident / Occurrence Reporting

An incident report (also called an occurrence or variance report) is a factual, objective, confidential document completed whenever an unexpected event occurs that could or did affect a client, visitor, or staff member. This includes actual injuries, medication errors, falls, equipment malfunctions, needle sticks, and near-misses where harm was averted. The nurse who witnessed or discovered the event files the report — not only the nurse involved in the event. The report is completed as soon as possible while details are fresh, and it documents exactly what happened, what was observed, and what actions were taken. Critically, the incident report is an internal risk-management and quality-improvement tool; it is NOT placed in the client's medical record. The medical record should contain only the objective clinical facts — vital signs, assessment findings, provider notification, and interventions — without any reference to the filing of an incident report. Referencing the report in the chart can compromise its legal protection. Incident data is aggregated to identify system-level patterns, not to assign individual blame. A just culture framework distinguishes human error, at-risk behavior, and reckless conduct — only the last warrants punitive action.