Rethinking Incident Investigations in Aging Services

Decisions made and actions taken in the first minutes and hours after an incident occurs in an aging services organization set the stage for everything else that follows. For instance, consider this hypothetical scenario:

A resident falls out of a lift, breaking a hip, but it is unclear what caused the fall. The lift is briefly checked by the staff involved, and they see nothing wrong, so the lift is not removed from service while the incident is investigated further. The next day, another resident falls from the same lift in a similar manner.

More scenarios like this one, many involving accidental injury to residents and seniors, play out in increasing numbers as the U.S. population rapidly ages.  Older adults are often more susceptible to incidents—and they're often more susceptible to injury. When something bad happens, it's an opportunity to learn how to improve and prevent others from being injured in the future.

So those who care for older adults need to be diligent in creating programs that continually monitor and evaluate safety issues and respond appropriately to incidents. This course of action is vital to reducing injuries in older adults and protecting organizations from risk, liability, and reputation damage.  

When an accident does occur, caring for the injured person(s) is the first priority. Each organization should have people, processes, and policies in place that outline how to do that successfully. But once the immediate crisis is under control, the next step is determining the cause of such events, mapping out a road to prevention, and reporting such incidents as mandated by law.

Accidents happen

Of course, your team’s ultimate goal is to prevent accidents. Unfortunately, they sometimes happen. How your organization responds to them is critical. Your organization should be prepared to launch a thorough investigation that focuses on fact finding and preventing future occurrences. 

This process is called a post-incident response. The initial investigation of an incident or near miss is designed to collect facts. Keep in mind that facts differ from interpretations and opinions. The organization will later analyze and learn from these facts with the goal of improving care and services. Thus, thorough and transparent investigations are critical.

Investigators should be well-trained and tireless in their pursuit of the facts. Anything less than their best effort can result in a lost opportunity to rectify a problem and increase resident safety. A faulty or non-transparent investigation also can undermine trust between the organization and residents and their families.

Phases of Post-incident Response

An investigation is a necessary step to improving resident safety, collecting facts, and complying with laws. Uncovering the facts and acting on them will ultimately lead to higher quality of care.

Generally, post-incident responses have three distinct phases that can contribute greatly to an organization’s efforts to prevent harm, reduce risk, improve quality, and increase safety.

1. Phase I - Initial identification and response

Incident investigations, which occur as part of Phase 1 activities, are a care critical part of initial post-incident response activities and therefore play an important role in collecting facts, complying with laws, and ultimately when acted upon greatly contributes to improving resident safety. An investigation must begin directly after notification of an incident because time is a significant factor. Time lost means information lost—facts, physical evidence, and even memories of witnesses.

Attending to injured people is the first step. Once that is under control, proper notifications must be made to internal and external parties, such as a shift supervisor on-site or the relative of an injured person.  Take steps to preserve equipment or other physical items that were involved in the accident. It’s also important to take preliminary steps to prevent a similar accident. This could mean removing a rug or other item that contributed to a fall, or posting a sign to warn of danger.

2. Phase II - Intermediate incident response 

This phase involves a lot of reporting and information sharing, so you’ll want to have a communication plan. You’ll also need to report the accident to outside agencies as required. Action is important here, too as analysis and performance improvement activities shift to quality assurance and performance improvement (QAPI), where the facts collected during the incident investigation are crucial for effective root cause analysis, problem-solving and performance improvement. Develop your performance improvement plan (PIP) and monitor any safety steps you already put in place immediately after the accident. Claims may arise in this phase, and the appropriate business and clinical staff members should manage that process.

You’ll continue to work on and monitor the steps mentioned in phases one and two.

Discovery: protected vs non-protected

It’s important to know what information to focus on and where each piece of information you uncover could be used during a lawsuit.

Your internal investigation must be limited to fact finding. Fact-finding documents including incident reports and witness statements often are not protected from discovery. The investigation’s findings then become a source of Quality Assurance Performance Improvement (QAPI) information to drive improvement.

Analytical tasks, like hypothesizing about the cause of an incident, analyzing evidence, and developing performance improvement recommendations, must be conducted under your QAPI program to be considered quality improvement work product and potentially qualify for protection from discovery in a lawsuit.  

Don’t let fear drive process

The threat of potential lawsuits looms heavy on administrators and clinical staff alike.  While residents’ safety remains the most important item on the agenda after an incident, investigators may worry that information they collect can lead to lawsuits.

Most importantly, a sub-par effort means you won’t discover the causes of and solutions to accidents. You may also be perceived as uncaring toward your residents, or as trying to cover up incidents or as misrepresenting facts to family members. This can undermine trust between the organization and the residents and families it serves, increasing the possibility of a claim or litigation. Ineffective investigations may also heighten the risk of regulatory citations or allegations of spoliation of evidence.

What went right

As you focus on what went wrong, don’t forget to take note of what went right. This information will help you identify processes that were successful and can be duplicated as you shape new solutions to prevent future accidents. Doing so also provides insight into how human beings within a system adjust and make decisions that promote safety in the context of a day-to-day work environment. This is often a forgotten focus of investigations and performance improvement, but it can be instructive. Aside from being a step in “investigation best practices,” it’s also good for morale to identify things that went right.

The take-away

Internal incident investigations can and should shape your organization's response to an accident. The information you learn will help prevent future harm, improve quality of care, and reduce risk—for residents and the organization. Completing the process effectively and transparently provides critical learning about the care you deliver and promotes trust among residents, staff, the organization, and family members. For more detailed guidance on incident investigations, download ECRI Institute’s white paper, Incident Investigation in Aging Services.