Incident Investigation in Aging Services

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In any healthcare management system, effective postincident response is a critical element of a facility’s resident and patient safety program and an important part of improving risk management, quality, and safety practices. This is especially true for aging services provider organizations, given the vulnerabilities that people tend to experience as they age. Decisions made and actions taken in the first minutes and hours after an incident set the stage for everything that follows.

The primary purpose of the initial investigation of an incident or near miss is to collect facts, which the organization will later analyze with the ultimate goal of improving care and services. Thus, thorough investigations are the foundation of efforts to learn from incidents and near misses. Even when an investigation is required (e.g., statute, regulation, an accreditor), aging services providers should optimize the opportunity to learn and improve.

When done well, internal incident reporting and initial investigations help to enhance quality and prevent incidents and resulting harm. The facts collected facilitate many postincident response practices, including but not limited to the following:

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