Week 5 – Find out and explain what happened

Week 5 – Find out and explain what happened

Further to apologising and expressing regret it is equally important that when things have gone wrong that we find out what happened and communicate this to the consumer/representative. In our commitment to being transparent and our focus on learning and continuous improvement it is important to gather all necessary information.

How we do this, might look different each time, dependent on the events that have occurred and the scale of harm.

To reiterate, this is not a process to apportion blame, instead it should be viewed as an opportunity for learning, with the aim to improve outcomes for consumers.

In aiming to understand the events/incident, information is sought from all key stakeholders, the consumer, representative, staff and others as applicable.

Some of the questions posed might include:

  • What happened? (this means gaining a detailed understanding of events)
  • Why did it happen? (what were the chain of events or causes of the event) and
  • How can it be prevented from occurring again? (this requires reflection, problem solving and implementing measures to avoid a recurrence).

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