Analysing incidents

The fourth step in the Incident Management System (IMS) cycle outlines how to analyse and investigate incidents.

Key actions

Know how to identify the root cause of an incident.
Understand your organisation's policies and procedures for analysing incidents.
Know your role in the incident analysis and investigation process.
Ensure your workers understand investigation policies and their role.
Ensure your policies and procedures clearly outline how and when to investigate an incident.
Ensure your policies and procedures empower management to use analysis and investigation as continuous improvement tools.

Conducting the analysis

You can use the 5-step problem-solving approach if an incident needs formal analysis.

You may not be directly involved in all 5 steps, but it’s essential to understand them. This ensures you’re ready to give feedback about any incident you’re involved with.

If unsure of your role in this process, read your service’s policy and speak to your manager.

Step 1: Define the problem

Understand what happened during the incident and who was involved.

Step 2: Determine the root cause

Consider what caused the incident and whether it requires internal or external investigation. Determining the cause early is vital for developing quick solutions.

Step 3: Develop possible solutions

Identify any solutions to fix the problem and prevent it from happening again.

Step 4: Select and implement a solution

Prepare, plan and implement an effective solution.

Step 5: Evaluate the outcome

Think about what is different and whether the solution works.

Example: Residential care

George lives in the memory support unit. Personal care worker Kelly hasn't seen George for an hour. She reports him as absent from care without explanation. A search of the facility doesn't find him.

The facility contacts the police and notifies George’s family. He is found at the local shops near the facility. He's confused and agitated but uninjured.

Due to the seriousness of the incident, management conduct an internal investigation. They also change some processes in the memory support unit.

Step 1: Define the problem

The service finds that George has a history of wandering. He was reported missing after a worker opened a facility door.

Step 2: Determine the root cause

The service discovers that George’s behaviour support plan had no information about the wandering risk. Interviews reveal that one worker forgot their facility key card on the day of the incident. This saw them prop a door open while working outside.

Step 3: Develop possible solutions

Possible solutions include:

reviewing George’s behaviour support plan
discussing the incident, investigation and actions with George’s next of kin
educating workers on their health and safety obligations
ensuring workers know and use relevant policies and procedures
reviewing organisational procedures to address gaps.

For information about steps 4 and 5, visit our Preventing incidents page.

Example: Home services

Hudson has a chronic medical condition that requires time-critical medication. His care plan states that workers must always have the medication with them. This is so he can take it when needed.

One of Hudson’s care workers, Luke, regularly drives him to do his grocery shopping. One morning at the checkout, Hudson tells Luke he is tired. Hudson points to a bench that he'd like to rest on.

When Hudson goes outside, he sees some friends sitting in the park. He crosses the road to say hello. He then accepts a ride home, forgetting about Luke.

When Luke leaves the shop, Hudson isn't where he said he would be.

Step 1: Define the problem

Hudson went missing while under Luke’s care. This is serious because his chronic medical condition requires him to take time-critical medication.

Step 2: Determine the root cause

Hudson was distracted when he saw his friends. He didn’t tell Luke he was going home with them.

The 2 didn’t discuss Hudson staying in one place so Luke could find him.

Step 3: Develop possible solutions

Possible solutions include:

identifying safe places where Hudson can rest during outings
setting clear expectations
advising Hudson to let Luke know if there are any changes
changing the time of outings so Hudson can take his medication before or afterwards
discussing Hudson getting a mobile phone so staff can contact him during outings
considering other shopping methods, such as ordering online, so Hudson has more time for different social outings.

For information about steps 4 and 5, visit our Preventing incidents page.

Other investigations

A formal internal or external investigation may be required for more serious incidents.

Your service should develop analysis and investigation policies that cover:

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.

The need for an internal investigation will depend on:

the nature of the incident
the impact on the person using aged care
identified incident patterns
feedback from those affected.

An incident may involve a criminal act or an unexpected death. In that case, relevant authorities such as the police or coroner will decide if an external investigation is necessary.