Adverse event Investigation Form - Convergint - UK

Clients Details

• Clients Name and Address

• Employers Name and Address

• Location of event (for example level 2 rear fire door exit)

• Conducted on

  Date

• Conducted by

• Type of Incident

  Select Good catch: An event that did not result in injury, illness, or damage, but had the potential to do so Minor injury: the injured person is unfit for normal work for less than three days (< 3day incapacitation ) Serious injury/ill health: the injured person is unfit to the normal work for more than three consecutive days (>3day incapacitation) Major injury/ill health: fractures (other than to fingers, thumbs and toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, or requiring admittance to hospital for more than 24 hours; ( >7 day incapacitation) Incident - Damage to property or structures

  • Good catch: An event that did not result in injury, illness, or damage, but had the potential to do so
  • Minor injury: the injured person is unfit for normal work for less than three days (< 3day incapacitation )
  • Serious injury/ill health: the injured person is unfit to the normal work for more than three consecutive days (>3day incapacitation)
  • Major injury/ill health: fractures (other than to fingers, thumbs and toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, or requiring admittance to hospital for more than 24 hours; ( >7 day incapacitation)
  • Incident - Damage to property or structures

• Name of person

• Date of birth

  Date

• Length of employment

• Type of injury

  Select Bruising Dislocation Strain/sprain Scratch/abrasion Internal Fracture Amputation Foreign body Laceration/cut Burn/scald Chemical reaction Other

  • Bruising
  • Dislocation
  • Strain/sprain
  • Scratch/abrasion
  • Internal
  • Fracture
  • Amputation
  • Foreign body
  • Laceration/cut
  • Burn/scald
  • Chemical reaction
  • Other

• Specify injured part of body

• Type of treatment given

  First Aid

  Hospitalisation

  No treatment required

• Who was the first Aider?

• Doctor/Hospital

• Date of hospital visit

  Date

• Treatment received at hospital

Details of Accident

• Which tasks was being conducted?

• Were potential hazards properly identified? (Written in the RAMS)

  Yes

  No

  N/A

• Were employees properly trained and proficient before performing the work?

  Yes

  No

  N/A

• Were established safe work procedures in place for the employee to follow?

  Yes

  No

  N/A

• Were employees following safe work procedures?

  Yes

  No

  N/A

• Was the proper personal protective equipment (PPE) specified for the job or task?

  Yes

  No

  N/A

• Did employees use the specific PPE?

  Yes

  No

  N/A

• Description

• Which action should be done to correct the situation?

• Responsible of the action

• Name of the injured person

• Date of birth

  Date

• Length of employment

• Type of injury

  Select Bruising Dislocation Strain/sprain Scratch/abrasion Internal Fracture Amputation Foreign body Laceration/cut Burn/scald Chemical reaction Other

  • Bruising
  • Dislocation
  • Strain/sprain
  • Scratch/abrasion
  • Internal
  • Fracture
  • Amputation
  • Foreign body
  • Laceration/cut
  • Burn/scald
  • Chemical reaction
  • Other

• Specify injured part of body

• Comments

• Type of treatment given

  First Aid

  Hospitalisation

  No treatment required

• Name of person giving first aid

• Doctor/Hospital

• Date of hospital visit

  Date

• RIDDOR completed

  Yes

  No

  N/A

• Name of the injured person

• Date of birth

  Date

• Length of employment

• Type of injury

  Select Bruising Dislocation Strain/sprain Scratch/abrasion Internal Fracture Amputation Foreign body Laceration/cut Burn/scald Chemical reaction Other

  • Bruising
  • Dislocation
  • Strain/sprain
  • Scratch/abrasion
  • Internal
  • Fracture
  • Amputation
  • Foreign body
  • Laceration/cut
  • Burn/scald
  • Chemical reaction
  • Other

• Specify injured part of body

• Was medical treatment recieved

  Yes

  No

  N/A

• What type of medical treatment

  Hospital (including A&E)

  First Aid only

  refused treatment

  other

  No treatment required

• Comments

• Is Convergint accountable for the the loss

  Yes

  No

  Partially

  Other

• USE PEME (Page 19/20 stages of an investigation)

• What is Convergint's involvement

Why did the adverse event occur

• Loss (what has been lost/damaged or injured for example broken ankle)

• How did it happen (for example slipped on ice)

• Immediate causes

• Why did this occur?

• Why did this occur?

• Why?

• Why?

• Underlying causes

• Why did this occur?

• Why did this occur?

• Why?

• Why?

• Underlying causes

• Why did this occur?

• Why did this occur?

• Why?

• Why?

• Root Cause (use information gathered from the why)

  Select People Equipment Material Environment

  • People
  • Equipment
  • Material
  • Environment

• Likelihood that an adverse event will happen again

  Select Certain - It will happen again and soon Likely: - it will reoccur but not as an everyday event Possible - it may occur from time to time Unlikely - it is not expected to happen again in the foreseeable future Rare - so unlikely that it is not expected to happen

  • Certain - It will happen again and soon
  • Likely: - it will reoccur but not as an everyday event
  • Possible - it may occur from time to time
  • Unlikely - it is not expected to happen again in the foreseeable future
  • Rare - so unlikely that it is not expected to happen

• Consequence

  Select Fatal: Work related death Major injury / ill health as defined under RIDDOR, schedule 1 including fractures (other than fingers and toes) amputations, loss of sight severe burn, any injury that results in loss of consciousness, requiring resuscitation or immediate transportation to hospital for more than 24 hrs. Serious injury/ ill health where the person is unfit to carry out their work for more than >3 consecutive days minor injury - all other injuries were the person is unfit to carry out their work for less than 3 days damage only - damage to property, equipment the environment or production losses

  • Fatal: Work related death
  • Major injury / ill health as defined under RIDDOR, schedule 1 including fractures (other than fingers and toes) amputations, loss of sight severe burn, any injury that results in loss of consciousness, requiring resuscitation or immediate transportation to hospital for more than 24 hrs.
  • Serious injury/ ill health where the person is unfit to carry out their work for more than >3 consecutive days
  • minor injury - all other injuries were the person is unfit to carry out their work for less than 3 days
  • damage only - damage to property, equipment the environment or production losses

• Use decision to investigate matrices on page 16 to identify level of investigation required

• Further investigation required

  Yes

  No

  N/A

Actions required

• What actions are required and by whom