Accreditation 2022: Incident Reporting at Women’s College Hospital

June 20, 2022

By Kathy Callfas

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Incident reporting is an important component of safety. By reporting potential or actual safety events, Women’s College Hospital (WCH) staff and physicians help prevent recurrences, enhance our understanding of safety risks, and contribute to a culture of safety.  At WCH, the primary mechanism for reporting safety events is the Incident Reporting and Information System, or IRIS for short. IRIS is available through an easy to find link on the WCH intranet home page ( As an added convenience, clinicians can also access IRIS via a navigation link within a patient’s health record (EPIC). Through this function, clinicians can quickly generate an IRIS report with patient demographic information seamlessly integrated within it.

Last year, WCH staff and physicians completed more than 900 IRIS reports! Numerous improvements have been implemented as a result including modifications to our clinical systems, enhancements to staff education, the development of new patient facing materials, and updates to WCH policy documents. Click here for the QTip.

Here are some useful tips for reporting incidents using IRIS:

  • The WCH staff member, physician, or learner who witnessed, was involved in, or first learned of the incident should complete the IRIS report. Supervisors or managers can assist individuals with limited access to hospital computers or who are unfamiliar with IRIS. 
  • Incident reports should be completed as soon as possible, preferably by the end of the working shift after the incident occurred or was discovered.
  • An actual incident is where an unsafe action or event has reached the patient/individual and has or could have resulted in harm ranging from “no harm to minor” to “severe to critical”.
  • A potential incident is any unsafe situation or event that did NOT reach the patient/individual but could have resulted in harm if it had. This type of event may also be known as a “near miss” or a “good catch”.
  • When documenting a safety incident in IRIS, it’s best to stick to facts. Avoid making assumptions or judgments and keep the language as objective as possible. 

To learn more about incident reporting at WCH visit the IRIS intranet page for resources including tip sheets, access to an IRIS training database, user guides, and links to relevant hospital policy documents. Please contact with any IRIS related questions or concerns.  

For more information about Accreditation, visit the Accreditation Intranet Hub