📋 Management of Care · Lesson 7 of 7 · 6 min

Incident Reports, Root Causes and Who to Refer To

🔎 A client gets the wrong dose. Nobody is harmed. The lazy response is a quiet shrug. The professional response is an incident report, a root cause analysis and a changed process, because the next client might not be so lucky.

💡 Key idea

Report every unusual event, analyze systems rather than people, and know which discipline to call: PT moves, OT adapts, speech swallows, social work connects.

🧠 Why it matters

An INCIDENT (occurrence) REPORT is filed for any event that is not consistent with routine care: medication errors, falls, equipment failures, injuries to visitors or staff, and near misses. Its purpose is QUALITY IMPROVEMENT, not punishment. ROOT CAUSE ANALYSIS asks why an event happened at the level of systems (look-alike labels, interruptions, understaffing) rather than blaming a person. A SENTINEL EVENT is an unexpected death or serious harm that requires immediate investigation. Nurses also coordinate care through REFERRALS: physical therapy for mobility and strength, occupational therapy for activities of daily living and adaptive equipment, speech-language pathology for swallowing and communication, social work for finances, housing and placement, case management for discharge planning and resources, dietitians for nutrition, and chaplains for spiritual care. Knowing who does what is a tested skill.

🏥 In the real world

🥄 A stroke client coughs every time she drinks. The nurse keeps her NPO and refers to speech-language pathology for a swallow evaluation, not to physical therapy. A thickened-liquid diet follows. One correct referral prevents an aspiration pneumonia.

📌 Takeaways

Incident reports capture errors, falls, equipment failures and near misses
Root cause analysis fixes systems, not scapegoats
PT for mobility, OT for ADLs, speech for swallowing, social work for resources

📖 Terms in this lesson

Incident report: An internal quality document filed for any unusual event, kept out of the client's chart and never mentioned in it.

✅ Test yourself

A client who had a stroke has trouble buttoning shirts and using utensils. Which referral is most appropriate?

Social work
Occupational therapy
Physical therapy
Speech-language pathology

Answer: B · Occupational therapy

Occupational therapy addresses fine motor skills and activities of daily living. Physical therapy focuses on mobility and strength.

What is the primary purpose of an incident report?

To protect the hospital from the client
To identify which employee to discipline
To find system problems and prevent recurrence
To document the event in the medical record

Answer: C · To find system problems and prevent recurrence

Incident reports feed quality improvement. They are internal, non-punitive and kept out of the chart.

A near miss occurs: a nurse catches a wrong-client medication before giving it. Should an incident report be filed?

Only if the pharmacy requests one for its own records
Yes; near misses reveal system weaknesses
No, because no harm occurred and the error was caught in time
Only if the client or family finds out about it

Answer: B · Yes; near misses reveal system weaknesses

Near misses are reportable precisely because they show where the next error will happen.

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