incident report

incident report

Incident Report: Improving Safety and Preventing Future Incidents

1. Introduction

It is important to remember that incidents are rare, unexpected and uncharacteristic events. People often investigate the wrong thing because they aren’t aware of the above statement. To clarify, an incident is not just an injury, spillage or equipment failure. These are just the results of an underlying or basic cause. For example, a broken ankle from a fall is just the result of poor balance, traction or a hazardous environment. An incident is a sequence of events which includes an initiating event, an initiating failure and specific action or result. These specific actions and results are the injuries/damage/losses we commonly identify as incidents. By determining the basic and underlying cause of an incident, we can prevent its re-occurrence or the re-occurrence of a similar incident in the future. This will involve development of recommendations. Step one identifies whether there is a need for changes to design, system or standards, or changes to compliance with existing standards. Step two identifies what actions can be taken to implement the changes identified in step one. Step three identifies performance indicators to determine if the actions taken have resulted in change, and if so, measure the change. Step four is evaluating the effectiveness of changes, and whether there have been any unforeseen impacts.

An incident is an unexpected and undesirable event. Incidents can disrupt routine activities in the workplace, disturb mental and physical well-being, involve huge or small costs, and lead to detrimental effects on the future. Incidents happen because people make errors, equipment fails, and the environment is different than what is expected. Learning about why incidents occur and how to prevent future occurrences is the purpose of investigating incidents. An incident investigation is a complex task that can be divided into two main phases. Phase one is the information gathering phase, and phase two is the analysis and development phase. During phase one, information is gathered in order to learn what happened and to identify all significant and the basic causes of the incident. During phase two, the causes are analyzed in order to develop recommendations which will prevent same, similar or other accidents in the future. This document is intended to guide you through the complete process from how to gather evidence and record the incident, to developing and reporting recommendations.

2. Incident Description

P – Patient with leg dressing changed I – Pain medicine administered during dressing change C – No time lost during care and medicine is paged later O – Comfortable patient and no interruption in nursing care

We can use a case study. Let us suppose we are caring for a patient who is receiving painful dressing changes on a leg wound daily. The patient is often anxious and requests pain medication before the dressing change. Nurses never seem to have time to administer the drug, and it has to be paged for later, interrupting the nursing care at an inconvenient time. This situation can clearly lead to PICO and can be simplified as below:

Actually, there are many types of research that can be done, but we’ll take William (2009) procedures in research. The independent variable is identified and manipulated, the dependent variable measures if the independent variable has an effect, then it explains how all that happens, data analysis, and the conclusion of the whole research. The reason why I chose this one is because it’s easy to identify the independent variable, it’s easier to find out what theory is being conducted, and the best thing is we can find the application and the theory itself has a good outcome.

An interesting goal of developing a middle-range theory in nursing is a very challenging one. It’s said that when we want to achieve something, we should have antecedent knowledge. Nowadays, the role of theoretical knowledge is very much needed for a nurse in order to produce a better outcome. According to Kearney-Nunnery (2008), theory-based practice focusing on risk reduction or preventative care has the greatest impact on patient health. When we talk about theory-based practice, we must have antecedent knowledge in the development of nursing practices. So, we can conclude here that theory is a structure that simplifies, and it is essential that “theory simplifies the complex.”

3. Investigation and Analysis

Beginning with the recognition of a problem, incident investigation is conducted to identify what, how, and why an event occurred in order to prevent future incidents. In this case, proper procedure was followed when setting out to resolve the issue. An incident report was promptly completed by the injured person and submitted to the supervisor. This was then followed up by a hazard report and the associated paperwork. An interview was conducted by the Safety and Health Coordinator several days later. All these documentation were brought to an Incident Review Team meeting arranged by the Safety and Health Coordinator. When analyzing the incident report structure, it was mentioned that too many different forms were to be filled out. This can be confusing. The injured person mentioned that she had forgotten that she had filled out the incident report when she filled out the hazard report. It was also questioned whether the right incident report form was used. This may include putting in place a system where it is only necessary to fill out one form, giving better explanation to the forms, or calling the Safety and Health Coordinator to guide the injured person through the process.

4. Recommendations for Improvement

There are several ways in which this crisis could have been either diverted or the damages reduced substantially. By taking a few strategic steps into consideration, our company can prevent current and future accidents and maintain a high standard when it comes to safety. The following are a list of recommendations we believe would assist all staff in preventing and or further accidents from happening. All staff should be trained to be sensitive, aware and understand the environment in which they are working. It is important to know what is volatile, reactive or hazardous. As a safety measure, containers and drums should be properly labelled. This would cut confusion in the event of further transfers and prevent unfortunate accidents such as this from occurring. In addition to this, it would be a wise decision to add temperature and pressure monitoring devices to the processors and storage units. This would allow staff to be aware of any irregular readings and to take any necessary action.

5. Conclusion

In conclusion, it is now understood that the best way to deal with an already diagnosed OHL problem is to accept it but exploit all the methods for reducing the friction heat induced damages. Simply because the author’s present post has concentrated only on causing mechanisms of friction heat damage and its sequential simulations to predict damage, the remedies have not been addressed at all. There are enormous means to an end in remedying friction heat damages and not only in the turbine blades or for OHL problems but spanning industries on a global scale and as the concept of exergy is relatively new for material engineers and metallurgists, there will not be a shortage of new ideas and technologies in the future. This is especially important in light of the OHL problem that is still ever present in light of the newly constructed advanced gas and steam turbines. It is the author’s hope though that by understanding the present post in depth, it onsets a new outlook for reducing friction heat induced damages, whilst increasing the useful efficiency of the power generation plant or other similar plant machinery. This is especially important during our ever increasing energy demands and concerns for greenhouse gas emissions. Only through these pathways of the exploitation of exergy and analysis of the second law of thermodynamics, can an appreciable impact be made.