This SOP outlines exactly what to do when any incident occurs at Besa Health. Incident reporting is not optional. It is not “extra paperwork.” It is how we protect:

  • Patients
  • Customers
  • Staff
  • The business
  • Our license
  • Our liability

If something happens, we document it. Every time.

🚨Use this link to submit an incident report

 

 

🚨 What Counts as an “Incident”?

An incident is any unexpected event that could impact safety, health, operations, or liability.

Examples include:

  • Patient injury (fall, fainting, reaction, etc.)
  • Customer injury (slip, burn, cut, etc.)
  • Medication issue (wrong medication, wrong label, missing dose, etc.)
  • Privacy issue (HIPAA concern, patient info seen/heard, paperwork left out)
  • Behavioral issue (threats, aggression, harassment)
  • Staff injury (needle stick, burn, fall, etc.)
  • Property damage
  • Theft or suspected theft
  • Safety hazards (water leak, exposed wires, broken equipment)
  • Any event requiring emergency services (911)
  • Any situation that “felt unsafe” or “could have been worse”

If you’re unsure whether it counts:

 ✅ It counts. Fill it out.

 

 

⏱ When an Incident Report Must Be Completed

An incident report must be completed:

  • Immediately after the situation is stabilized
  • Before the end of the shift
  • The same day the incident occurred

There are no exceptions.

 

 

🛑 Step 1: Stabilize the Situation First

Before paperwork, you must ensure safety.

You must:

  • Stop the activity if needed
  • Remove hazards (wet floor, broken item, unsafe equipment)
  • Provide appropriate assistance
  • Notify a supervisor/manager immediately
  • Call 911 if needed

Incident reporting does not replace emergency response.

 

 

📣 Step 2: Notify Leadership (Immediately)

As soon as the situation is safe, you must notify:

  • On-site supervisor or manager
  • Clinic leadership (if patient-related)
  • Operations leadership (if facility-related)

If it involves:

  • Injury
  • HIPAA/privacy
  • Medication
  • Aggression/threats
  • Police/911

You must escalate immediately.

 

 

📝 Step 3: Complete the Incident Report (Same Day)

Incident reports must be:

  • Completed by the staff member who witnessed the incident OR
  • Completed by the person directly involved (if safe and appropriate)

If multiple staff witnessed the event:
Each witness must submit a statement.

 

 

✍️ What Must Be Included in Every Incident Report

Every incident report must include:

  • Date and time of incident
  • Exact location (front desk, exam room, café counter, restroom, etc.)
  • Names of people involved (patient/customer/staff)
  • Names of witnesses
  • Clear description of what happened (step-by-step)
  • What actions were taken immediately
  • Whether medical attention was offered or required
  • Whether 911/police were called
  • Any equipment involved
  • Any photos taken (if appropriate)
  • Whether the person declined help or left
  • Any follow-up steps needed

     

🚫 What You Must NOT Do

Incident reports must be factual — not emotional, not opinion-based.

You must NOT:

  • Guess what happened
  • Assign blame
  • Write assumptions
  • Apologize in writing on behalf of the company
  • Admit fault (“This was our mistake,” “We caused this,” etc.)
  • Argue with the person involved
  • Promise compensation or refunds unless leadership approves

Stick to facts only.

 

 

📌 How to Write It 

Use this format:

1) What happened (facts only):
2) What was observed:
3) What actions were taken:
4) Who was notified:
5) Outcome:

Example wording:

  • “Patient reported dizziness and sat down.”
  • “Customer slipped near the condiment station.”
  • “Water was observed on the floor.”
  • “Wet floor sign was placed immediately.”
  • “Manager notified at 2:14 PM.”
  • “Patient declined EMS.”

     

📤 Step 4: Submit the Report Properly

Incident reports must be submitted:

If you are unsure where to submit. You must ask a supervisor immediately. Do not leave the report “for later.”

 

 

🔒 Confidentiality 

Incident reports are confidential internal documents.

You must NOT:

  • Discuss incidents casually with coworkers
  • Share details with friends or family
  • Post anything on social media
  • Show incident reports to anyone not authorized

HIPAA still applies. Always.

 

 

🧾 Documentation Rules 

Incident reports are:

  • Not medical records
  • Not part of the patient chart
  • Not to be uploaded into the EHR unless instructed by leadership

They are internal risk and safety documentation.

 

 

🚫 Non-Negotiables

  • All incidents must be reported.
  • Incident reports must be completed the same day.
  • Leadership must be notified immediately.
  • Reports must be factual only.
  • No guessing. No blaming. No admitting fault.

Confidentiality is mandatory.