Learning From Incidents and Near Misses in Moving and Handling: Improving Safety Without Increasing Restriction
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Incidents and near misses during moving and handling are inevitable in physical disability services, yet how providers respond to them determines whether practice improves or becomes more restrictive. Too often, incidents trigger blanket restrictions such as increased hoist use or reduced independence without analysing underlying causes. Commissioners and inspectors increasingly expect providers to evidence learning cultures that improve safety while preserving autonomy.
This article explores how physical disability services can learn from moving and handling incidents and near misses. It should be read alongside Learning from Incidents and Positive Risk-Taking & Risk Enablement.
Why incidents lead to restriction
Incidents often create fear and urgency. Managers may feel pressure to act quickly, and staff may lose confidence. Without structured review, restriction becomes the default response.
This can undermine long-term outcomes and increase dependency.
Commissioner and inspector expectations
Two expectations are consistently applied:
Expectation 1: Evidence of learning, not just action. Inspectors expect providers to show how incidents inform safer practice.
Expectation 2: Proportionate post-incident responses. Commissioners expect restrictions to be justified, time limited and reviewed.
Structured incident review for enablement
Effective reviews examine environment, communication, fatigue, equipment and staff judgement, not just the individual’s actions.
Operational example 1: Learning from a transfer incident
Following a transfer incident, a provider identified time pressure and poor communication as root causes. Adjustments improved safety without reducing independence.
Using near misses as early warning signs
Near misses provide valuable learning opportunities without harm. Capturing and analysing them can prevent escalation.
Operational example 2: Responding to repeated near misses
A service noted repeated near misses during evening transfers. Staffing patterns were adjusted, reducing risk without introducing restrictions.
Closing the learning loop
Learning must be translated into updated plans, training and supervision. Without follow-through, incidents repeat.
Operational example 3: Embedding learning into practice
A provider introduced action trackers linking incident learning to plan updates and staff briefings. Inspectors highlighted this as good practice.
Governance and assurance
Providers should evidence learning through:
- Trend analysis of incidents and near misses
- Management oversight of post-incident restrictions
- Review of enablement outcomes over time
From incidents to improvement
In physical disability services, learning from incidents should strengthen, not weaken, independence. Providers that respond proportionately are better placed to evidence quality, reassure commissioners and deliver safer, enabling support.
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