Title Page
Incident location:
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Fitzroy
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East Melbourne
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Kew
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Department:
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Location in department:
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Conducted on:
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Conducted by:
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WHS/Executive member:
Incident Details
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Date & time of incident:
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Staff injured/involved:
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Description of incident:
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Has a Riskman been completed?
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Enter Riskman number:
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Did the incident result in a work related injury which resulted in the person being absent from work for at least one full shift?
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Enter details
Communication
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Were issues relating to communication a factor in this event?
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Enter details
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Communication issues between staff?
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Communication issues between staff and patient/family/carer?
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Documentation?
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Patient Assessment?
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Information not provided
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Misinterpretation of information
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Other
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Knowledge, skills & competence:
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Were issues relating to knowledge/skills/competence a factor in this event?
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Staff training/skills?
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Staff competency?
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Staff supervision?
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Use/not use/misuse of equipment?
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Other
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Were issues relating to work environment/scheduling a factor in this event?
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Were issues relating to the work environment a factor in this event?
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Enter details
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Work place design?
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Suitability of work environment?
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Environmental stressors?
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Safety assessments/evaluations/procedures?
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Shortage of beds/rooms/resources?
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Staff roster/timetable?
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Other
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Were issues relating to patient factors an issue in this event?
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Communication difficulties?
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Medical history/known risks?
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Patient's condition?
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Personal issues?
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Other
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Were issues relating to Equipment (including the use or lack of use) a factor in this event?
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Communication difficulties?
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Enter details
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Medical history/known risks?
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Enter details
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Patient's condition?
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Personal issues?
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Other
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Were issues relating to policies, procedures and guidelines a factor in this event?
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Absence of relevant, up-to-date policies, procedures or guidelines?
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Implementation issues?
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Education/training?
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Issues in applying policies, procedures or guidelines?
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Absence of audit/quality control system?
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Other
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Were issues relating to safety mechanisms a factor in this event?
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Lack of appropriate safety process/systems in place?
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Breakdown of safety process/system?
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No evaluation of safety process/system?
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Other
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Other
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Were there other factors involved in the event which do not fall into the above categories, please provide details:
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Enter details
Recommendations/outcomes:
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Recommendation 1
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Person responsible:
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Completion date:
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Recommendation 2
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Person responsible:
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Completion date:
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Recommendation 3
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Person responsible:
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Completion date:
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Recommendation 4
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Person responsible:
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Completion date:
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Recommendation 5
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Person responsible:
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Completion date:
