Analysing the incident | Aged Care Quality and Safety Commission

Overview

The third phase of the IMS cycle is continuous improvement. Analysis is critical to driving continuous improvement. The third phase of the IMS cycle starts with analysing the incident, element 4.

Analysis forms the foundation of this continuous improvement phase and is closely linked to implementing actions and closing the loop.

IMS Cycle Phase 3 includes: Element 4 analyse the incident; element 5 implement actions; and element 6 close the loop

Key actions

Ensure you know how to identify the root cause of an incident
Ensure workers understand investigation policies and their role in procedures
Your policies and procedures must clearly outline how and when an incident should be investigated
Ensure your policies and procedures empower management to use analysis and investigation as tools to drive continuous improvement

Key actions

Make sure you understand the importance of incident analysis
Make sure you understand your provider’s incident analysis policies and procedures
Make sure you know your role in the analysis and investigation processes

How to conduct an analysis

A problem-solving approach can be used to:

critically assess incident data
identify and implement targeted solutions
measure success of solutions.

For more serious incidents, you may need to conduct a formal investigation. One way to conduct an analysis or investigation is to use the 5-step problem solving approach.

How to conduct an analysis

Your service may use a problem-solving approach to:

critically assess incident data
identify and implement targeted solutions
measure success of solutions.

For more serious incidents, your service may need to conduct a formal investigation. One way to conduct an analysis or investigation is to use the 5-step problem solving approach.

Step 1 Define the problem, step 2 determine the root cause, step 3 develop possible solutions, step 4 select and implement a solution, step 5 evaluate the outcome

Analysis in practice

An analysis should follow each incident, although the level and extent of the analysis may vary. You should follow these 3 steps of the problem-solving process:

Analysis in practice

You may not be directly involved in all steps of the analysis process. However, it will benefit you to understand the process so that you are ready to contribute whenever your input might be required for an incident you were involved in.

An analysis should take place each time an incident occurs in connection with care, although the level and extent of the analysis may vary. You should follow these 3 steps of the problem-solving process:

Consider the details of the incident

01. Define the problem.

Who was involved/impacted?
Where and when did it occur?

02. Determine the root causes of the problem.

Examine the causes – how and why did this incident occur?
What were the contributing factors?
Determine whether a formal internal investigation is required.

03. Develop possible solutions.

What risks did you identify?
What changes can you made to reduce the risk of this incident occurring again?

If you are unsure of your role in the incident analysis process, refer to your service’s IMS policies and speak with your manager.

Example

George, a consumer living in the memory support unit, was reported as absent from care without explanation by personal care worker Kelly after she did not see him for an hour, and he could not be located following a search of the facility. Police were contacted immediately, and the family notified. George was found not far from the facility at the local shops. He was not injured but was very confused and agitated. Due to the seriousness of the incident, management conducted an internal investigation.

As part of this investigation, you examined George’s history of wandering and the incident details. You determined that George's cognitive impairment and a worker leaving a door open contributed to this incident. Actions, including some changes to the service's processes in the memory support unit, have been implemented.

Example

A consumer, Hudson, has a chronic medical condition that requires time-critical medication. Luke, one of Hudson’s care workers, regularly drives him to the shops to do his grocery shopping. It is documented in Hudson’s care plan that care workers must always have his time-critical medication with them so Hudson can take it when he needs it, including when he is out.

One morning, as they were finishing the shopping and waiting at the checkout, Hudson told Luke he was feeling tired and pointed out the bench he would go to, to rest. When Hudson went outside, he noticed some of his friends sitting in the park and crossed the road to say hello. While chatting, they offered him a ride home and he accepted but forgot about Luke. When Luke stepped out of the shop, Hudson was not where he had said he would be.

Analysing the incident

01. Define the problem.

The service determines that George has a history of wandering and was reported missing after a door to the facility was left open by a worker.

02. Determine the root causes of the problem.

The service discovers that George's Behaviour Support Plan (BSP) did not include any information on his risks of wandering. Interviews with workers reveal that one worker had forgotten their key card to the facility the day of the incident and propped a door open while working outside.

03. Develop possible solutions.

The provider’s findings and actions include to:

1. review George’s Behaviour Support Plan (BSP)

2. discuss the incident and the service’s investigation and actions with George’s next of kin. This includes a recommendation to discuss care plan updates

3. educate workers with a focus on resident health and safety obligations and ensuring everyone knows and uses relevant policy and procedures

4. review organisational procedures to ensure there are no gaps.

Analysing the incident

01. Define the problem.

Hudson went missing while under Luke's care.

This is serious due to Hudson’s chronic medical condition and the requirement to take time-critical medication to help manage the symptoms of his condition.

02. Determine the root causes of the problem.

Hudson was distracted by his friends and did not tell Luke he would go home with his friends.

Hudson and Luke did not discuss the need for Hudson to stay in the one spot, so Luke could locate Hudson easily.

03. Develop possible solutions.

Some possible solutions:

if Hudson gets tired easily on outings, identify safe places where he can take a rest
Luke can set clear communication expectations with Hudson, and Hudson must let him know if there are any changes
explore the option of changing the time of shopping outings so Hudson can consistently have his medication at home either before or after the outing
explore the option of Hudson having a mobile phone so he can be contacted on outings if care staff cannot find him
Hudson and Luke can consider other methods for shopping, such as ordering online together. They could select ‘Click and collect’ or get the shopping delivered. This would free up time for Hudson to have other social outings.

Note: Ensure the root cause is determined early to allow prompt development of solutions.

It is also necessary to train and educate workers about their role in this process and set clear expectations.

Following the 5-step framework, this problem-solving process is continued in the Implementing actions stage.

Different levels of analysis

For more serious incidents, a formal investigation may be necessary. Investigations may be conducted internally or externally. The decision to conduct an internal investigation should consider the nature of the incident, the level of impact on the consumer, identified incident patterns, and feedback/views from those affected.

For incidents involving acts of a criminal nature or where an unexpected death occurred, the relevant authority (for example, police or the coroner) will determine the need for an external investigation.

For further information, visit the Effective serious incident investigations guidance for providers.

Investigation and safety cultures

The purpose of internal investigations is not to identify a ‘guilty’ person to blame for an incident.

Your service should build a safety culture where you feel comfortable reporting incidents.

You can contribute to this safety culture by understanding your role in incident analysis and investigation and by promoting open discussion of continuous improvement.

Investigation and safety cultures

The purpose of internal investigations is not to identify a ‘guilty’ individual to blame for an incident.

Your service should build a safety culture which supports workers to feel comfortable reporting incidents. Workers should feel confident that improvements will be made to your service based on incident analysis and investigation outcomes.

You should develop relevant policies for your service, including:

how and when to analyse an incident
the criteria and process for an internal investigation
how serious incidents are escalated and investigated internally
how your service engages in external investigations.

Like other IMS policies, ensure these are regularly reviewed and effective, for safety and continuous improvement purposes.

You must report any incidents involving a crime to the police, who will undertake their own investigation if required.

Your service’s analysis and investigation policies and procedures should include:

how and when to analyse an incident
the criteria and process for an internal investigation
how serious incidents are escalated and investigated internally
how your service engages in external investigations.

Ensure you familiarise yourself with your service’s policies and procedures.

Incident assessment

As part of your approach to managing and preventing incidents, you should assess all incidents to determine the appropriate support to provide to those impacted, and any reasonable and proportionate remedial actions to be taken.

In doing this, you must assess:

whether the incident could have been prevented
any remedial actions to be undertaken to prevent or minimise similar incidents from occurring
how well the incident was managed and resolved
what, if any, actions could be taken to improve your management and resolution of similar incidents
whether other persons or bodies should be notified of the incident

You are responsible for undertaking any actions identified through your assessment, including to notify the relevant person(s) identified, minimise risks, prevent future incidents from occurring and improve your approach to managing incidents.

Your service must report any incidents involving a crime to the police, who will undertake their own investigation if required.

Work tool

Use the 5 step problem-solving approach template when analysing or investigating an incident.

Contact us

If you have a question about the SIRS, you can call us on 1800 081 549. This phone line is open 9 am to 5 pm (AEST) Monday to Friday and 8 am to 6 pm (AEST) Saturday to Sunday.

You can also email us at sirs@agedcarequality.gov.au.

Facilitated workshops

The Commission provides facilitated workshops to sector participants. All current workshops are available on the Commission’s Workshop page.

Online learning

The Commission’s Aged Care Learning Information Solution, Alis provides free online education for employees of Commonwealth-funded aged care providers, including modules about incident management systems.

You can access Alis at learning.agedcarequality.gov.au.

Disclaimer

The information contained on this page is intended to provide you with general guidance; however, it is your responsibility to be aware of your legislative requirements.