Incident management | Aged Care Quality and Safety Commission

Legislation
Guidance

Outcome Statement

The provider must use an incident management system to safeguard individuals and acknowledge, respond to, effectively manage and learn from incidents.

Actions

2.5.1

The provider implements an incident management system to record, investigate, respond to and manage incidents and near misses that occur in connection with the delivery of funded aged care services and reduces or prevents incidents from recurring.

2.5.2

The provider takes timely action to respond to and manage incidents.

2.5.3

The provider supports individuals and supporters of individuals to report incidents and encourages their involvement in identifying ways to reduce incidents from occurring.

2.5.4

The provider supports the workforce including through provision of tools, training and clear policies to prevent, recognise, respond to and report incidents.

2.5.5

The provider collects and analyses incident data and reports to the relevant regulator as required. All outcomes are reported to individuals and aged care workers and feed into the provider’s quality system to improve the quality of funded aged care services.

2.5.6

The provider regularly reviews and improves the effectiveness of the incident management system and communicates changes to aged care workers and individuals.

Why is this outcome important?

Outcome 2.5 explains providers’ obligations to manage and respond to incidents well. You’re responsible for having an incident management system to identify, document, respond to and manage incidents. This includes making sure responses to incidents and near misses are timely. This is important to safeguard the health and wellbeing of older people. This also helps to create an environment that encourages accountability, transparency, trust and safety.

By collecting, analysing and integrating incident data in your quality system, you can identify organisation-wide issues and trends. This can help you to learn from incidents, strengthen your strategies to mitigate risk and improve the safety of aged care services you provide. Managing incidents in this way supports your overall quality system and drives continuous improvement.

You need to give focus to:

supporting and encouraging older people and workers to:
- report incidents
- identify ways to stop incidents from happening.
incident management responsibilities for workers.

All providers need to have an incident management system to record and respond to reportable incidents. Providers delivering aged care services in a residential care home have a 24-hour responsibility to manage incidents that occur. Providers delivering aged care services in a home or community setting have a responsibility to manage incidents that occur during the delivery of aged care services by the provider’s workers and associated providers. Providers delivering aged care services in a home or community setting are also expected to protect the safety, health and wellbeing of older people by responding to and learning from incidents that occur outside the delivery of their aged care services. For example, by recording the incident, reviewing the older person’s care and services plan and reporting matters to other authorities where needed in accordance with local jurisdictions requirements.

All registered providers are responsible for reporting incidents that occur at a service they have sub-contracted to an associated provider. They should have processes in place to support this.

Key Tasks

Put in place an incident management system.

At a minimum, make sure your incident management system outlines:

clear and documented processes, roles and responsibilities on how you:
- acknowledge incidents
- record incidents
- assess and investigate incidents
- respond to incidents
- manage incidents
- resolve incidents
- learn from incidents, to prevent or reduce future incidents from happening again.
categories to define an incident. Be clear about what an ‘incident’ or ‘near miss’ includes. This definition needs to be clear about what an incident is in the context of the organisation’s scope of services. Include situations that have, or could, cause harm to a person. The categories need to be in line with the Serious Incident Response Scheme (SIRS). They also need to include harm or possible harm to:
- an older person
- a member of their family
- a worker
- another person providing aged care services.

Incidents can be clinical or non-clinical. Incidents can also relate to worker safety.

Outcome service context

In aged care services delivered in a home or community setting, incidents that occur during the delivery of aged care services may be managed differently from providers delivering aged care services in a residential care home. Providers delivering aged care services in a home or community setting should have strategies in place to record incidents, including incidents reported by others. For example, by supporting older people, their supporters, family and carers to report incidents as they occur. This could be done through:

regularly talking to older people, their supporters, family and carers
providing clear instructions on what to report and how to report the incident when it occurs
offering alternative contact options as an accessible way of reporting incidents, if it involves the worker responsible for delivering direct care to the older person,
making sure they feel supported, listened to and understood when they raise issues.

Use your incident management system to report and respond to incidents.

Have clear processes to respond to each type of incident that can happen when you deliver aged care services. Outline who needs to be involved and the timeframe when you need to carry out key activities. Key activities can include reporting, investigations and sharing information.

Incidents that you need to report include near misses, as well as incidents that:

have happened
are alleged or suspected, even if you can’t confirm the incident.

Serious incidents must be reported following the Serious Incident Response Scheme (SIRS) process. These are incidents where older people have been harmed or were at risk of harm.

Have clear processes to record and report different types of incidents. Include:

who reports incidents
how to document an incident report
what level of detail to put into an incident report
how to submit the incident report
how long you have to submit an incident report.

After an incident:

be clear who is responsible for deciding on immediate actions to keep older people and workers safe
review an older person’s care and services plan if an incident involves them (Outcomes 3.1 and 5.4)
investigate the cause of an incident. Make sure incidents are investigated. This is to find and manage the underlying cause of an incident and prevent it from happening again. Be open about the outcome of the investigation. Share this with the older person, their supporter, families and carers if the older person chooses to.
look for trends to find organisation-wide issues and ways to improve and communicate changes to workers and older people. Do this as part of your broader performance monitoring activities (Outcome 2.3). For example, an organisation-wide issue could be:
- aspects of care which aren’t delivered well. These may suggest that your organisation needs additional worker training.
- older people regularly fall in a particular spot at the service delivery location and you need to redesign the area to be safer.
use your incident management system to monitor and review the strategies you have to manage the cause of the incident and the risk of it happening again.
report incidents to the relevant regulator. You may also need to report incidents to other authorities in line with your state or territory legislation.

If you receive a complaint after an incident or near miss, integrate this information with your feedback and complaints management system (Outcome 2.6a and 2.6 b).

Have an incident reporting form and incident register. Record key information about each incident that has happened.

Outcome service context

Providers delivering aged care services in a home or community setting also have a responsibility to respond to and learn from incidents that occur outside of their direct delivery of aged care services. They should have processes to:

enable the recognition, escalation and reporting of such events
document these events
review the older person’s care and services plan.

If a provider delivering aged care services in a home or community setting becomes aware of an incident that occurred outside of scheduled aged care service delivery (such as physical assault or any other unlawful act), they should consider how this may affect the older person’s safety, health, wellbeing and ongoing care needs. While a serious incident notification to the Commission is not required in these circumstances, providers should also assess what additional supports the older person may need. This may include:

reporting the matter to police if it involves criminal conduct, or to other authorities in line with local jurisdiction requirements. Where this is required, providers delivering aged care services in a home or community setting should have processes in place to partner with the older person when making police reports, to keep them informed and mitigate potential concerns.
connecting the older person with advocates and other support services, if this is what they want.

Put in place strategies to help workers manage incidents well.

Put in place policies and procedures that support you to use your incident management system. Make sure these are:

current and informed by the latest contemporary, evidence-based practices
regularly reviewed
clear and accessible for workers and relevant people.

Provide workers with tools, guidance and training on how to use the incident management system (Outcome 2.9). This needs to be in line with:

the organisation’s policies and procedures
workers’ roles and responsibilities.

Make sure workers understand:

their role in the incident management system
how to use the system to manage incidents when delivering aged care services to older people.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management.

Monitor how well you use the incident management system.

Regularly review your incident management system to make sure it works well. Look for ways to improve the system.

To check if your incident management system works well, you can review:

older people’s aged care service documents (Outcome 3.1)
complaints and feedback (Outcome 2.6)
information about incidents
worker performance and how well they’re using the incident management system. You can do this through quality assurance and system reviews (Outcome 2.9).
policies and procedures.

Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they feel their provider supports them to report incidents and involves them in finding ways to reduce incidents. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their supporters and others they may want to involve, such as family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.

Further resources about this outcome can be found on the Commission's Quality Standards Resource Centre.

Outcome 2.5: Incident management

Outcome 2.5: Incident management

Outcome Statement

Actions

Why is this outcome important?

Key Tasks

Update to guidance