Incident Investigation Report (Version 1)

• Incident Number / Reference:

• Conducted on:

  Date

Investigation Team

• Name:

• Organisation:

• Role:

Property Details

• Property Name:

• Property Address:

• Ward / Area Name:

Details of Incident Report

• Incident Number / Reference:

• Reported By:

• Line Manager:

• Organisation:

• Date of Incident:

  Date

• Incident Type:

  Select Death Major Injury Lost Time Minor Injury Near Miss Other

  • Death
  • Major Injury
  • Lost Time
  • Minor Injury
  • Near Miss
  • Other

Executive Summary A brief narrative of facts obtained from incident report:

Details of Injured Person (Leave blank if not applicable)

• Injured Person:

  NHS PS Employee

  Tenant

  Patient

  Member of Public

  Contractor

• Nature of Injury: (list all that apply)

  Select Abrasion, scrapes Amputation Asphyxiation Broken bone / Fracture Bruise Burn (heat) Burn (Chemical) Concussion Crushing Injury Cut / Laceration Damage to a body system Hernia Illness Puncture Sprain, strain

  • Abrasion, scrapes
  • Amputation
  • Asphyxiation
  • Broken bone / Fracture
  • Bruise
  • Burn (heat)
  • Burn (Chemical)
  • Concussion
  • Crushing Injury
  • Cut / Laceration
  • Damage to a body system
  • Hernia
  • Illness
  • Puncture
  • Sprain, strain

• Other, Please State:

• Other Complications and immediate remedial actions:

• Multiple Casualties?

  Yes

  No

• If yes, how many?

• Loss of consciousness?

  Yes

  No

• Resuscitation required?

  Yes

  No

• First Aid?

  Yes

  No

• Hospital?

  Yes

  No

• Advised to see GP?

  Yes

  No

• OH Intervention required?

  Yes

  No

Narrative of Events A detailed chronological narrative of events leading up to and including the accident, as well as rescue and medical actions taken after the accident. This section will contain who, what, and where.

• Pre-Incident:

• Incident:

• Post-Incident:

Investigation Process A brief narrative of actions taken by the investigation team. This narrative should include investigation team membership, Delegation of Authority information (from who and contents), investigative actions and timeline (when the team conducted interviews, inspections, site visits etc.) and if other sources were consulted (I.e. professional accident reconstruction experts, equipment manufacturers, etc.). This section should also address if environmental, equipment, material, procedural, and human factors were present, and state how findings/recommendations were developed.

Root Cause of the incident A root cause is an initiating cause of a causal chain which leads to an outcome or effect of interest. Commonly, root cause is used to describe the depth in the causal chain where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome.

• Unsafe workplace condition (tick all that apply)

  Select Inadequate Guard Unguarded Hazard Safety device is defective Tool or equipment defective Workplace layout is hazardous Inadequate Lighting Poor Ventilation Lack of PPE provision Lack of appropriate equipment/tools Unsafe clothing No training or insufficient training No risk assessment or not adequate for the task

  • Inadequate Guard
  • Unguarded Hazard
  • Safety device is defective
  • Tool or equipment defective
  • Workplace layout is hazardous
  • Inadequate Lighting
  • Poor Ventilation
  • Lack of PPE provision
  • Lack of appropriate equipment/tools
  • Unsafe clothing
  • No training or insufficient training
  • No risk assessment or not adequate for the task

• Other, please state:

• Unsafe acts by people (tick all that apply)

  Select Operating without permission Operating at unsafe speed Servicing equipment that is still energised Making a safety device inoperative Using defective equipment Using equipment in an unapproved way Failure to follow safety procedures Adopting an unsafe position or posture Distraction, teasing, horseplay Failure to wear PPE Failure to use the correct equipment/tools Failure to supervise adequately

  • Operating without permission
  • Operating at unsafe speed
  • Servicing equipment that is still energised
  • Making a safety device inoperative
  • Using defective equipment
  • Using equipment in an unapproved way
  • Failure to follow safety procedures
  • Adopting an unsafe position or posture
  • Distraction, teasing, horseplay
  • Failure to wear PPE
  • Failure to use the correct equipment/tools
  • Failure to supervise adequately

• Other, please state:

• List all causations for the incident under the following headings where applicable:

• Task

• Material

• Environment

• Personnel

• Management

• Why did the unsafe conditions exist? (Was it outside NHS PS control?)

• Why did the unsafe acts occur? (Poor safety culture, individual limitations, perception, attitude etc.)

• Is there a perceived reward (such as "the job can be done more quickly" or "the product is less likely to be damaged") that may have encouraged the unsafe conditions or acts?

  Yes

  No

• If yes, describe:

• Were there any unsafe acts or conditions reported prior to the incident?

  Yes

  No

• Have there been any similar incidents or near misses prior to the one?

  Yes

  No

Findings and Recommendations

• Findings:

• Discussion:

• Recommendations: What changes/actions do you suggest to prevent this incident/near miss from happening again?

  Select Stop/suspend activity Guard the hazard Train employee(s) Train Supervisor(s) Redesign Task Redesign Work Area Enforce existing procedures Write new procedure Replace plant or machinery Routinely inspect for hazards Personal Protective Equipment Implement/improve maintenance and/or inspections

  • Stop/suspend activity
  • Guard the hazard
  • Train employee(s)
  • Train Supervisor(s)
  • Redesign Task
  • Redesign Work Area
  • Enforce existing procedures
  • Write new procedure
  • Replace plant or machinery
  • Routinely inspect for hazards
  • Personal Protective Equipment
  • Implement/improve maintenance and/or inspections

• Other, detail below:

Conclusion and Observations Investigation team's opinions and inferences, and 'lessons learned' may be captured in this section.