Template for serious patient safety incident report
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Description of the content for the tool user
This report template is intended for use by organisations investigating serious patient safety incidents. Users can modify it according to the needs and policies of their organisations.
The purpose of reporting and handling serious patient safety incidents is to improve safety and prevent similar incidents in the future. A systematic handling process helps to understand the causes of the incident, identify risks and shortcomings in operations, and implement corrective measures. This process is an integral part of safety management and the organisation’s safety system.
An investigation report is compiled on the investigation of a serious patient safety incident. It is typically the only document from the investigation that is retained after the investigation. The investigation report is retained by the organisation in accordance with its own guidelines.
The report is based on all the information available to the investigation team. It represents the investigation team’s view of the incident and the factors that led to it. The investigation report is also a document describing how the serious hazardous incident has been handled in the organisation’s self-monitoring process and what measures have been taken on the basis of this.
The aim of the investigation report is to promote learning from the incident and the sharing of information. The report should adequately describe the incident and related deviations, as well as the reasons for the selected development recommendations.
A high-quality investigation report is clear, neutral and objective. When writing the report, it is important to remember that the reader must be able to understand the connections between different aspects without having any other information about the incident.
The final investigation report on a serious patient safety incident should not contain any information that could identify the parties involved or reveal the sources of the information.
Although serious patient safety incidents do occur, in most cases care/services proceed as planned and successfully. It is therefore a good idea to also look at the process of serious patient safety incident from the perspective of success and to note what went well in the situation and what was successful.
Further information: Investigation of serious adverse events. Guide for social and health care organisations. Publications of the Ministry of Social Affairs and Health 2023:31. (In Finnish)
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This tool has been developed by Strategy Group 3.1 of the Client and Patient Safety Strategy Action Programme. The tool has been circulated for comments to all strategy groups of the Finnish Centre for Client and Patient Safety, the Self-Regulation Procedures Cooperation Group and the Consensus Group on Indicators. The tool was approved by the Expert Council on 6 February 2025.
Further information: Finnish Centre for Client and Patient Safety (noharm(a)ovph.fi ).
Published on 25 February 2025. Publisher: Finnish Centre for Client and Patient Safety. The need to update the tool is reviewed annually.