When something goes wrong in an aged care setting—whether it is a fall, medication error, or equipment failure—your response matters. Not just the first response, but what you do after the dust settles. That is where an incident review comes into play.

Think of an incident review like a backyard clean-up after a storm. The wind has blown down branches and scattered leaves everywhere. You cannot stop the storm, but you can learn how it messed up your garden and find better ways to keep it tidy next time.

This blog will walk you through how to run a post-incident review in aged care that is practical, people-focused, and actually helps prevent the same problem from happening again.

Why Post-Incident Reviews Matter

Running a good incident review is not about pointing fingers. It is about understanding what happened and making your care home safer for residents and staff. It is about stepping back and asking, “What went wrong? Why? And how can we do better?”

When done well, an incident review can lead to:

• Clear learning outcomes
  
• Better teamwork
  
• Improved communication
  
• Stronger ‍
• Stronger hazard management in aged care

In short, it helps everyone breathe a little easier.

Step 1: Call a Time-Out

After an incident, it is easy to jump back into your usual routine. But before the moment slips away, you need to press pause.

Take time to gather a small group of people who were involved. This might include care workers, nurses, housekeeping staff, or anyone else who saw or responded to the incident. Invite them to share what they saw and felt.

Keep it casual. Brew a pot of tea, bring in some biscuits, and sit down together. You are not running a courtroom—you are opening a conversation.

Step 2: Stick to the Facts

At this stage, focus on what actually happened. Avoid jumping to conclusions or guessing.

Ask:

• What was the resident doing before the incident?
  
• Where did it happen?
  
• What time was it?
  
• Who was around?
  

Get clear answers and write them down. This helps build a timeline of the incident. You want the picture to be sharp, not fuzzy.

You can even use a big piece of butcher paper to draw a map or timeline. Sometimes people remember more when they can see it sketched out.

Step 3: Dig for the Root Cause

Now you start asking the deeper questions. The goal is to find the root cause—the thing at the bottom of the pile that really caused the incident.

Imagine a cracked window. You can tape it up again and again, but until you find out why it keeps cracking, it will never stop.

In aged care, root causes might include:

• Poor lighting in hallways
  
• Slippery floors
  
• Staff under pressure
  
• Confusing medication labels
  

Use the “5 Whys” method. Keep asking “Why?” until you get to the bottom.

Example:

• Why did the resident fall?
  
  • Because they tried to go to the bathroom alone.
    
    
• Why did they go alone?
  
  • Because they could not find their call bell.
    
    
• Why could they not find their call bell?
  
  • Because it had fallen behind the bed.
    
    
• Why did it fall behind the bed?
  
  • Because the cord was too short.
    

And there you have it. A root cause you can fix.

Step 4: Focus on the Learning Outcomes

This part is like finding the gold nugget in the riverbed. You have sifted through the mud and rocks, and now you want to keep what matters.

Ask the group:

• What did we learn from this?
  
• What should we do differently next time?
  
• Who needs to know about this?
  

Turn your findings into clear learning outcomes. Keep them short and simple. Put them on the wall in the staff room if you like.

Some examples:

• Always check that call bells are within reach
  
• Use non-slip socks for residents who walk without shoes
  
• Ask residents if they need help before bedtime
  

The best learning outcomes are easy to follow and make sense to everyone—from kitchen hands to senior nurses.

Step 5: Do Not Forget the Feelings

Incidents do not just affect the resident. Staff can feel upset, guilty, or worried too. Taking a moment to check in with everyone’s emotional state is not only kind, but smart.

Say things like:

• “That must have been tough.”
  
• “I am really glad you were there to help.”
  
• “How are you feeling about what happened?”
  

You are not expected to be a counsellor, but showing empathy builds trust and helps people speak openly.

Step 6: Put the Plan in Motion

You have done the talking. Now it is time for doing.

Choose 2 or 3 changes you will make based on what you learned. Assign someone to each one. Keep it simple.

For example:

• “Emma will check that all resident call bells are working during the morning shift.”
  
• “Dan will ask maintenance to fix the lighting near Room 12.”
  
• “Jo will update the handover notes to remind staff about night-time checks.”
  

Small steps can make a big difference. What matters is doing them well and checking in a week or two later.

Step 7: Share What You Found

Once you have run your incident review, let others in the care home know what came from it. Share the key points during staff meetings, or send around a short bulletin.

Make it friendly and short. Try something like:

“Last week, a fall happened near Room 8. After our review, we found the lighting was too dim. We are replacing the bulb and reminding night staff to bring torches. Please keep an eye out for trip hazards in dim areas.”

Sharing helps create a culture where people care, speak up, and act on what matters.

Common Mistakes to Avoid

Nobody gets this right every time. But watch out for these bumps in the road:

• Blaming people instead of focusing on systems
  
• Rushing through the review just to tick a box
  
• Making learning outcomes too vague
  
• Failing to follow up on action items
  
• Keeping it all a secret
  

You would not put a bandage on a cut and then pretend it never happened. Same goes here. Follow-through is key.

How Incident Reviews Help with Hazard Management

Running regular post-incident reviews also helps with hazard management in aged care. Each review gives you clues about what needs fixing or changing.

Over time, you will spot patterns:

• Are most incidents happening during shift changes?
  
• Is one hallway always involved in falls?
  
• Are residents confused by similar-looking medicine bottles?
  

Spotting these patterns helps you tackle hazards before they lead to another incident. Think of it as clearing the rocks out of the path before someone trips.

Make It Part of the Routine

The more you do it, the easier it gets. Incident reviews should not feel like a special event. They should be part of your weekly rhythm.

Like washing the linen or checking the fridge temp, post-incident reviews keep your aged care home running safely.

Set up a simple checklist to guide each review. Stick it on the wall. Share it during team training. Make it your new habit.

Final Thoughts

Running an incident review is not about ticking off a task. It is about listening, learning, and improving bit by bit.

It is about making sure residents feel safe, staff feel supported, and everyone knows they are part of a team that cares enough to ask: “What happened, and how can we make it better?”

No fancy tools required. Just open ears, kind hearts, and a shared goal: keeping your aged care home as safe and caring as it can be.