Audit

Incident location:

Fitzroy

East Melbourne

Kew

Department:

Location in department:

Conducted on:

Conducted by:

WHS/Executive member:

Incident Details
Date & time of incident:

Staff injured/involved:

Description of incident:

Has a Riskman been completed?

Enter Riskman number:

Did the incident result in a work related injury which resulted in the person being absent from work for at least one full shift?

Enter details

Communication

Were issues relating to communication a factor in this event?

Enter details

Communication issues between staff?

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Communication issues between staff and patient/family/carer?

Enter details

Documentation?

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Patient Assessment?

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Information not provided

Enter details

Misinterpretation of information

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Other

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Knowledge, skills & competence:

Were issues relating to knowledge/skills/competence a factor in this event?

Enter details

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?

Enter details

Other

Enter details

Were issues relating to work environment/scheduling a factor in this event?

Were issues relating to the work environment a factor in this event?

Enter details

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?

Communication difficulties?

Enter details

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?

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 policies, procedures and guidelines a factor in this event?

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?

Lack of appropriate safety process/systems in place?

Enter details

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

Were there other factors involved in the event which do not fall into the above categories, please provide details:

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Recommendations/outcomes:

Recommendation 1

Person responsible:

Completion date:

Recommendation 2

Person responsible:

Completion date:

Recommendation 3

Person responsible:

Completion date:

Recommendation 4

Person responsible:

Completion date:

Recommendation 5

Person responsible:

Completion date:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.