An incident management system is much more than just a list of incidents in a spreadsheet. It is a thorough approach to preventing, managing, and learning from incidents. For an incident management system to be effective, it:

• Needs strong leadership commitment and an organisational culture that prioritises openness, accountability, and ongoing improvement in safety and quality.
• Must be built within a solid governance framework.
• Should include clear, detailed policies and procedures for handling incidents and near misses.
• Should provide an easy-to-use system for recording incidents, ensuring they are stored securely and accessible when needed.
• Must be well understood and actively used by both staff and customers, as well as their families and representatives.
• Should allow you to respond to incidents by:
  • Quickly identifying and addressing an incident, while offering immediate support to those affected.
  • Properly reporting, notifying, and documenting the incident.
  • Reviewing, analysing, and investigating the cause of the incident when needed.
  • Making necessary changes to reduce the risk of recurrence and improve safety.

• Helps you continually improve, share insights, and identify trends.
• Should be regularly evaluated and updated.

The following sections discuss these key elements of an effective incident management system.

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Leadership commitment and organisational culture

Effective incident management starts with strong leadership and a supportive organisational culture. Critical enablers for success in incident management include:

Leadership Support and Commitment

• Effective incident management needs visible support from leadership at all organisational levels.
• This begins with the board or governing body and must be present through the CEO (or equivalent) and the leadership team.
• customers and staff need to clearly see that the organisation is genuinely committed to incident management.

A Culture of Safe, Inclusive and Quality Care Delivery

• Providing safe and quality care requires building and maintaining a culture that places a strong emphasis on safety and quality in care.
• This includes a culture that:some text
  • Puts customers at the heart of their care.
  • Encourages openness, honesty, fairness, and accountability.
  • Promotes the reporting of incidents and near misses.
  • Helps staff feel comfortable identifying incidents and near misses as they occur.
  • Provides opportunities for staff training and preparedness.
  • Promotes a mindset of learning, understanding, and continuous improvement.
• Culture cannot simply be imposed through policies and procedures. Instead, it is shaped by the attitudes, understanding, and behaviours of staff over time.
• Everyone in the organisation plays a role in fostering and maintaining a culture that learns from incidents and strives for continuous improvement in care and services.
• A culture of safe, inclusive, and quality care is embedded in every part of the organisation. This is driven by leadership decisions and the overall direction set by the governing body, influencing how the organisation communicates its values and purpose to its workforce, customers, and the community.

Tips for Fostering Cultural Change

• Encourage a culture where learning from mistakes is valued.
• Address cultural barriers that might prevent staff or customers from reporting incidents and adjust communications and training accordingly.
• Highlight the importance of effective incident management and prevention to both staff and customers.
• Ensure the board regularly reviews data on incidents, near misses, trends, investigations, and the actions taken.
• Address behaviours that contradict a blame-free culture and commitment to learning.
• Engage with other organisations to learn how they gained leadership support and achieved cultural change in incident management.
• Review your organisation’s values to ensure they align with a focus on safety, quality care, openness, and continuous improvement.

1. Effective organisation-wide governance

Organisation-wide governance ensures authority is managed across all levels of the organisation, from the governing body to staff. This structure supports effective incident management and prevention, as outlined in Standard 8 of the Quality Standards.

Key elements of governance include:

• ‍Information Management: Staff need easy access to information to prevent and manage incidents, including guidelines for reporting and learning.‍
• Continuous Improvement: Incident data should drive continuous improvement efforts, linking incident outcomes to safety and quality improvement plans.‍
• Financial Governance: Financial systems should ensure that corrective actions from incident investigations are supported in the organisation’s budget.‍
• Workforce Governance: Clear responsibilities for incident reporting and management must be assigned across the workforce.‍
• Regulatory Compliance: Incident management helps meet various regulatory requirements, including safety and professional standards.‍
• Feedback and Complaints: Incidents often come through feedback and complaints. These must be integrated into the incident management system for follow-up and action.

2. Comprehensive policies and procedures

A solid incident management system needs clear, accessible policies and procedures. These guide everyone—staff, customers, and families—on identifying, managing, and resolving incidents.

Key areas to cover:

Roles and Responsibilities:

• Define staff roles in handling incidents and near misses.
• Outline who reports incidents to authorities like the Commission.
• Ensure staff know their responsibilities and receive role-specific training.

Identifying, Recording, and Reporting Incidents:

• Clarify what incidents and near misses are.
• Specify how to record them, including necessary details for analysis.
• Explain internal reporting processes, including who to report to and when.

Notifying Others:

• Detail when to notify customers, families, or emergency contacts.
• Specify when to involve the police, emergency services, or government bodies (like AHPRA or NDIS authorities).

Supporting Those Affected:

• Outline how to support individuals affected by incidents, ensuring their safety and wellbeing.
• Encourage involving those affected in the resolution process.
• Use open disclosure to communicate transparently when things go wrong.

Reviewing and Investigating Incidents:

• Establish a process to review incidents:
• Could it have been prevented?
• Was it managed well?
• What actions can prevent future incidents?
• Define when and how to conduct in-depth investigations into causes and impacts.

Remedial Actions:

• Identify situations requiring corrective steps, like preventing recurring risks.
• Examples include:
• Updating governance practices
• Providing staff or consumer training
• Improving the service environment or care processes

Clear, well-implemented policies ensure consistent incident responses and build trust within your organisation.

3. Supporting and educating staff on incident management

Your incident management system only works if the staff:

• Understand their roles and responsibilities.
• Feel safe reporting incidents and near misses.
• See incident management as part of delivering quality care, not a separate task.

Here are the key steps to support staff:

Clarify Roles and Responsibilities: Ensure all staff—whether employed directly or through agencies—know their duties regarding:

• Identifying, recording, managing, and preventing incidents.
• Reporting incidents to the right people within set timeframes.

Provide Comprehensive Training:

• Train all staff on how to use and comply with the system, tailored to their roles.
• Include non-care staff since they may be the first to notice or respond to incidents.

Reinforce and Remind Regularly:

• Emphasise that incident management isn’t just about reporting; it’s about responding, supporting customers, and learning.
• Encourage staff involvement in analysing incidents and suggesting improvements.

When everyone is well-informed and confident, incident management becomes a shared responsibility, improving safety and care quality.

4. Encouraging customers, families, and representatives to report incidents

Creating an open and transparent environment helps customers feel safe and confident in reporting incidents. This is especially important when customers worry about consequences or feel reluctant because they have positive relationships with staff members.

Here are some key strategies to encourage reporting:

• Communicate the Benefits: Explain how an effective incident management system improves care and safety for everyone.
• Engage Proactively: Involve customers and their families in discussions about reporting, showing them that their input leads to real improvements.
• Provide Clear Guidance: Ensure they know how to report incidents, share information, and participate in finding solutions.

When customers see that their reports lead to positive changes, trust grows, making the system stronger and more effective for all.

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How to respond to incidents

1. Identifying incidents

Incidents and near misses can be identified in several ways. These include when a staff member or another consumer observes an incident, a consumer discloses an incident, or someone else informs staff that an incident may have occurred.

Your incident management system should clearly outline expectations for staff identifying or suspecting an incident.

Some incidents are easy to identify, such as when a staff member witnesses an event or a consumer reports it. However, other incidents, like abuse or neglect, can be harder to detect. Near misses may also be challenging to identify because no harm occurs, but they indicate potential risks. Recognising near misses, where an error or hazard could have caused harm without intervention, is crucial for learning and improvement.

It is your responsibility to ensure all staff are trained to identify and report incidents and near misses.

customers may disclose information about incidents they experienced, were involved in, or heard about. All such disclosures must be taken seriously and investigated.

For customers with cognitive impairment, any reported incidents must be investigated, even if they may involve delusions. If repeated reports are found to be untrue, support the consumer appropriately and document the reports in your incident management system.

Some customers may fear reporting incidents due to concerns about retaliation or losing services. Staff should remain alert to signs that someone may have experienced an incident, even if it is not directly reported.

Potential indicators of reportable incidents are further discussed in the NDIS Commission Reportable Incidents Guidance, Serious Incident Response Scheme Guidelines for residential aged care providers and Serious Incident Response Scheme Guidelines for providers of home services.

2. Immediately supporting those affected

When an incident occurs, you should take immediate action to protect the health, safety, and well-being of those involved. The support and assistance needed should be assessed, taking into account the level of harm or impact on those affected, and the actions that can reduce harm and ensure everyone’s physical and psychological wellbeing.

Having a response plan in place for handling incidents is a good practice. It can help protect everyone involved and prevent future incidents. This plan might include:

Immediate Action:

• Check on those involved to assess any harm, engaging a clinician if needed.
• Provide timely and appropriate support or treatment based on the level of harm.

Engage with Those Affected:

• Inform consumer representatives about the incident as soon as possible.
• Help them access advocates or external support services like the Older Persons Advocacy Network (OPAN).
• Arrange meetings with those affected (and their representatives) to apologise and discuss how the incident is being handled.
• Keep them updated about the cause, what’s being done to fix it, and how future incidents will be prevented.

Assess Risks to Others:

• Support and reassure others who may have witnessed the incident.
• Provide updates about the incident’s cause and steps being taken to prevent similar events in the future.

Reportable Incidents:

• Notify relevant authorities, such as the NDIS Quality and Safeguards Commission, Aged Care Quality and Safety Commission, police, coroner, or AHPRA.
• Conduct internal investigations to determine what caused the incident.

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How to report and record incidents (including notifications)

1. Reporting incidents 

Organisations handle incident and near-miss reporting in different ways, often using paper or electronic forms. Serious incidents with a high potential for harm may also be reported verbally for quick action. Reporting helps determine the next steps, such as whether further investigation or resources are needed. Staff responsible for reviewing reports should analyse the facts and collect any extra information to understand what happened.

Reporting starts a series of notifications to different parties, depending on the incident. The parties might include:

Customers – Engage with the affected consumer and their family or representative as soon as possible. Disclosure is an ongoing process that may require multiple conversations. Practical support, such as providing contact information for emotional or physical assistance, should be offered early. Open communication, showing compassion, and offering an apology help both customers and staff heal and rebuild trust.

Commission – If the incident is classified as a ‘reportable incident’ under the NDIS Quality and Safeguards Commission, or Serious Incident Response Scheme (SIRS), you must notify the related Commission within specific timeframes, which - in most cases - is within 24 hours. Detailed guidelines for reporting are available for NDIS support and service providers, residential aged care providers, and home service providers.

Reporting to the Coroner – Deaths may need to be reported to a coroner, especially if they involve unexpected, unnatural, or violent causes, or if a doctor cannot issue a death certificate. Each state and territory has specific rules for reporting deaths to the coroner.

Police – If there are reasonable grounds to report an incident to the police, such as ongoing danger, contact them and other emergency services within 24 hours of becoming aware of the incident. Some jurisdictions also require police notification for certain deaths, including unexpected ones.

Others – Depending on the nature of the incident, you may need to make additional notifications. For example, if the incident is workplace-related, you may need to inform Safe Work Australia (or the equivalent in your state). If the incident involves the professional conduct of a registered health practitioner, notify AHPRA. If the incident involves a notifiable disease or condition, contact local public health units. 

Ultimately, clear, timely, and respectful communication, both internally and externally, will help build trust with all stakeholders, including the public.

2. Recording incidents

Although each provider’s incident management system may vary, all systems should be able to record key details about any incident or near miss. The following table outlines these essential details. By collecting this information, you will also have everything needed to notify the Commission about a reportable incident.

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Your system for recording incidents should:

• Collect data and information to review and address issues raised by incidents, identify patterns, and report to the Commission when required.
• Allow you to identify recurring incidents or patterns of abuse and support reportable incident notifications to the Commission.
• Safely and securely store incident records (e.g., electronic systems should prevent unauthorised access, and paper records should not be taken home by staff).
• Clearly define who is responsible for collecting incident information. Incident-related records should be kept together.
• Retain incident records for 7 years after the incident date, in line with best practices for records management.
• Maintain privacy and confidentiality of information, particularly customers’ personal details. Personal and sensitive information should be securely stored and transmitted within your organisation or to external parties (e.g., police, Commission).
• Ensure proper use of a notice of collection when gathering personal or sensitive information related to an incident.
• Follow privacy protection guidelines as outlined in the Aged Care Act and relevant privacy laws such as the Privacy Act 1988.

For more details on requirements, refer to the NDIS Commission Reportable Incidents Guidance, or the Serious Incident Response Scheme guideline for residential aged care providers and providers of home services.

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How to investigate and analyse the incident

Immediate actions may be needed to reduce the risk of harm and prevent recurrence. It is important to keep customers, families/representatives, and staff informed about these actions. Additional steps typically follow after a thorough analysis is completed.

The type and extent of the analysis (or investigation, if needed) depend on the nature of the incident. Several factors can influence the approach, including:

• The severity of the incident
• The impact on consumer and family/representative confidence and safety
• The likelihood of recurrence
• Whether a similar incident has occurred before
• Whether the incident shares underlying causes with past incidents
• Whether the incident involves individuals who have been involved in other incidents
• The complexity of the incident (e.g., unclear facts or causes)
• Whether the incident is a reportable incident under the NDIS Commission Guidance or the SIRS
• The views of the affected parties (including customers, families/representatives)

These factors help determine who should be involved in the analysis, whether a formal investigation is necessary, and whether the investigation should be conducted internally or independently. In certain situations, an independent investigation may be more appropriate, such as when the facts are in dispute, when there is an allegation of inappropriate staff behaviour, or if the consumer or their family/representative requests it.

An investigation or analysis typically looks into:

• The underlying causes of the incident
• Any additional actions required to address the incident
• Measures to prevent similar incidents in the future, including necessary systemic changes

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How to implement changes to reduce recurrence 

In some situations, remedial action is necessary to prevent similar incidents in the future. After any incident, it’s important to assess whether:

• The incident could have been prevented or its impact reduced through action taken by you or a staff member
• There is an ongoing risk to customers, visitors, staff, or others
• There are actions you or your staff could take to reduce or eliminate the risk of recurrence

Remedial actions may include:

• Providing or requiring training or re-training for staff, either individually or across the service
• Adjusting the organisation’s governance frameworks, whether clinical or otherwise
• Reviewing, updating, or creating new service procedures to help staff manage emerging risks
• Making changes to the service environment or the equipment used to provide care
• Promoting a safe care culture, such as emphasising incident management during staff inductions
• Allocating additional staff to assist customers with certain tasks
• Seeking specialist assistance or implementing new strategies to manage consumer behaviours
• Updating care planning documents to address the root causes or impacts of the incident

Alongside these actions, it may be necessary to take disciplinary measures with staff, such as performance management, probation, suspension pending an investigation, or termination of employment.

It’s your responsibility to ensure that all necessary remedial actions are carried out and to keep those affected by the incident updated on the outcomes or progress of these actions. Any organisational changes made as a result of the incident should be communicated clearly to customers, their representatives, staff, and relevant service providers.

Tip: Choosing Appropriate Remedial Actions

When deciding on appropriate remedial actions, consider these three key questions:

• What is the goal we want to achieve?
• How will we measure if the change leads to improvement?
• What changes can we make to ensure long-term improvement?

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Closing the loop

1. Analysing incident trends and data

Your incident management system should allow you to collect and analyse data on incidents, enabling you to:

• Identify and address systemic issues in care quality
• Spot recurring incidents or near misses, including suspected or alleged occurrences
• Recognise trends and patterns in incidents, such as certain behaviours
• Provide staff with feedback and training on preventing and managing incidents
• Share information with the Commission as requested

Regularly reviewing and analysing incident data will help you identify opportunities for organisational improvement. This process, as part of your broader risk management strategy, should focus on trends, common incidents, causes, and feedback from customers, staff, and others. You can use these insights to enhance organisational learning, improve care and services, reduce risks to health, safety, and wellbeing, and improve the management and prevention of incidents.

2. Continuously improving and sharing learnings

It’s essential to share lessons learned both within and outside the organisation. This sharing helps prevent further harm and makes aged care safer. Without this exchange of information, similar incidents could recur.

Learning from incidents and near misses, understanding what can be done to prevent them, and building trust are key elements of an effective incident management process. The results of investigations or analyses should be part of regular organisational reporting and shared with the board, leadership team, staff, those affected by the incident, and the public. It may also be valuable to share these learnings with other providers and peak bodies.

3. Reflecting on and Improving the incident management system

Your incident management system should be regularly monitored to ensure it remains effective and reliable. Ongoing monitoring helps identify areas for further improvement. Set aside time and resources to assess how well your processes are working. This review ensures that processes are appropriate, reliable, use resources and staff efficiently, and aim to improve care and services.

Continuous learning from incident analysis is essential for rebuilding trust, restoring relationships, and fostering a safe organisational culture. When evaluating incident analysis and the effectiveness of remedial actions, consider factors such as:

• The timeliness of the analysis
• Whether remedial actions were implemented
• How effective those actions were in preventing recurrence
• Feedback from those affected by the incident
• How well the learnings were shared within the organisation

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Manage incident effectively with Pnyx

With the Pnyx Quality Management System, incident management becomes seamless, proactive, and impactful.

Our system helps you log, track, and resolve incidents efficiently, ensuring every detail is captured and every action is accounted for. With compliance tools, customizable templates, and real-time analytics, you stay audit-ready all time. Pnyx enables your team to respond faster, learn from incidents, and continuously enhance the quality of care.

Learn how Pnyx helps you take control of incident management and turn every challenge into an opportunity to deliver exceptional care.