Aged care incident management procedure

Purpose

To make sure every incident and near miss involving a client is responded to straight away, recorded accurately, reported to families and the regulator when required, and investigated, so the same thing doesn’t happen again.

Scope

Every incident and near miss involving a client, whether in a residential service, the client’s home or the community, including falls, medication errors, injuries, missing clients, and any allegation of abuse or neglect. It applies to all staff, contractors and volunteers.

Responsibilities

Definitions

Incident

Any event that harmed, or could have harmed, a client, such as a fall, an injury, a medication error or an allegation of abuse.

Near miss

An event that could have caused harm but didn’t, because it was noticed in time or by chance.

Reportable incident

An incident your regulator requires you to report, within set times.

Open disclosure

Talking openly with the client and their family about what happened, saying sorry, and explaining what is being done.

What you need

• The incident form or system
• The on-call manager’s phone number
• The regulator’s reporting process and deadlines
• The client’s care plan and their contact and representative details

Procedure

1. Make the client safe

   Give first aid, stay with the client, and call emergency services if they need medical help. Make the area safe for others.

2. Get help and tell the person in charge

   Tell the person in charge or the on-call manager straight away, and keep the client supervised.

3. Protect the evidence

   For an alleged assault or a serious injury, leave the area and anything involved as it is, and don’t clean the client unless their care needs it.

   Caution: If a staff member is alleged to have harmed a client, keep them away from that client and from other clients until the manager decides what happens next.

4. Record what happened

   Before the end of your shift, record the facts on the incident form, what you saw and heard, the client’s own words, who was there, and what was done. Don’t guess or blame.

5. Tell the family or representative

   The person in charge tells the client’s family or representative what happened, as the client wishes and your policy says.

6. Decide whether it’s reportable

   The incident manager decides whether the regulator must be notified, and how quickly, using your regulator’s criteria.

   Caution: Some serious incidents must be reported within hours. Don’t wait for the investigation to finish before you notify.

7. Notify the regulator and the police

   Notify the regulator within the time it sets, and the police where a crime may have happened. Record when and how each was notified.

8. Talk openly with the client and family

   Explain what happened, say sorry, and tell them what is being done to stop it happening again.

9. Investigate

   Find out how and why it happened, talking with the staff, the client and any witnesses. Look for causes in the systems, not only in people.

10. Act and update the care plan

    Agree actions with owners and dates, update the client’s care plan, and train staff on any change.

11. Close and review trends

    Close the incident when the actions are done. Each month, review all incidents and near misses for patterns, such as falls at the same time of day.

Records

• The incident record, with the response, the investigation, the actions and when it was closed, kept for as long as your rules require.
• Notifications to the regulator, the police and the family, with dates and times.
• Open disclosure conversations and what was agreed.
• Monthly incident trend reviews and the actions taken.

Related documents

• Incident management policy
• Elder abuse and safeguarding procedure
• Open disclosure policy
• Falls prevention procedure

Revision history