Running Head: ACCIDENT REPORT 1

Workplace Accident Report: Lower Back Injury

Trisha Belen

Iqra Butt

 Jisha John

 Lysis Placides

Jennifer Whitaker

BSHW 2502

April 5th, 2020

Workplace Accident Report: Lower Back Injury

Purpose and Objective

Incident investigations are an important component of an Occupational Health and Safety

program (Kelloway, 2011). There are many reasons and benefits for conducting an incident

investigation within a workplace; for instance, they determine direct causes, identify contributing

factors, prevent similar incidents from occurring, and promote safety awareness among

employees (Kelloway, 2011). Having said that, it is important to address incidents that occur

within the workplace as soon as possible to promote a healthy and safe environment for all

workers. The purpose of this report is to conduct an investigation of a physical incident that

occurred two days ago at a healthcare facility. We will identify the possible causes of the

incident and apply recommendations into practice to prevent it from occurring in the future. 

Description of Incident (See appendix A):

 Registered Practical Nurse Jane has been working at a Toronto healthcare facility for

over two years. On March 28th, 2020, Jane sustained a severe lower back injury from

transferring a patient to bed. She completed the transfer using a mechanical lift and was also

accompanied by a new Team Leader Mr. Diaz, to assist with the transfer (See appendix A).

Critical Factors in the Investigation Process

Incident investigations are strongly influenced by timing, severity and legal requirements

(Kelloway, 2011). An important factor to consider is the time from when an incident occurs, to

when an incident investigation takes place. Any impedance in conducting an incident

investigation can lead to partial or complete memory loss by eye-witnesses, adjustments at the

site where the incident occurred, and or removal of evidence that was at the scene at the time of

the incident - all in which can affect the overall investigation process (Kelloway, 2011). In Jane’s
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case, the investigation took place two days after the incident occurred. Furthermore, the severity

of an incident is also a critical factor in an investigation process. Because investigations are time-

consuming, the corporate director of health and safety states that incidents that result in either

lost-time injuries, cause serious injuries or close calls - are mainly when investigations are

conducted (Kelloway, 2011). Therefore, because Jane’s incident resulted in serious injuries, the

incident will be investigated. 

Information Collected

In addition, incidents can occur in the workplace due to various contributing factors.

These factors are important to evaluate when conducting an incident investigation because it can

prevent similar incidents from occurring in the future. We examined human factors, situational

factors, and environmental factors that contributed to Jane's lower back injury.  

Human Factors:

Human factors are important to consider while conducting an incident investigation.

Identifying possible human factors does not necessarily mean that the individual involved in the

incident is at fault, rather it is to collect facts and data (Kelloway, 2011). At the time of the

incident, Jane and Mr. Diaz were performing a regular task of their job duties by performing a

two-person transfer using a ceiling lift. These two staff members were following the transfer

according to the company’s policies and procedures. Although there was no manager present at

the scene, Jane has been working for the company for over a year and has over three years of

experience in her field. On the other hand, Mr. Diaz is new and working on his first shift

independently in the company. An unsafe act that may have contributed to the event was that Mr.

Diaz failed to properly adjust the harness on the patient and safely secure him to the machine.

This could have also resulted due to a lack of training on how to operate the machine as he is
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new to learning. Furthermore, because the patient weighed approximately 90kg and required

immediate assistance, it caused Jane to react quickly to save the patient, thus leading Jane to use

incorrect body mechanics. 

Situational Factors: 

Another important element we considered during this incident investigation were

situational factors. These factors are the unsafe working conditions that may have contributed to

the incident; this can also include any equipment or tools that were used (Kelloway, 2011). The

location in which the incident occurred was in a patient's room at the healthcare facility. The

incident took place at approximately 2100 which was close to the end of Jane's evening shift.

The transfer required the use of a mechanical lift because the patient was unable to stand and

transfer himself independently. In addition, a wheelchair was also used during the incident.

Environmental Factors:

Environmental factors such as noise and lighting are also important to consider when

conducting an investigation (Kelloway, 2011). For instance, the lighting in the patient’s room

prevented Jane and Mr. Diaz from seeing if the harness was properly secured on the patient -

especially because it happened at night. In addition, there was inadequate space to move around

which prevented Jane from properly positioning herself to transfer the patient. This also

prevented Mr. Diaz from navigating the machine and wheelchair to its proper position, to safely

transfer the patient.

Legal Requirements

Since Jane had a work-related injury, she is eligible to receive worker’s compensation of

benefits. These benefits are payments made to the injured worker to cover the cost of loss of

earnings and loss of functional capacity (Kelloway, 2011). According to the Workplace Safety
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and Insurance Act, an employee must report their injury as soon as possible to the supervisor

within three days (Kelloway, 2011). It must be reported if the worker requires treatment from a

health professional, is absent from work, or earns less than their regular pay (CCOHS, n.d.). 

Jane reported her injury to an occupational health nurse 2 days after the incident occurred

(See appendix A). The occupational health nurse provided Jane with a copy of Notice of Injury

Employer Form (Form 7) which she took to her healthcare provider (HCP) to notify them that

she was injured at work (WCB, n.d.). Jane’s HCP completed the required paperwork (Form 8) to

help the Worker’s Compensation Board create a decision of her claim (WCB, 2020). A

representative from WCB took the details and information to prompt Jane to fill the Worker

Online Incident Report (WCB, 2020). Once all forms are completed and approval of benefits are

pending, Jane is entitled to sick time in her collective bargaining agreement (CUPE, n.d., p. 14)

Investigative Methods

When conducting an incident investigation, various methods can be used; such

as walkthrough and observations at the site of the incident, conducting interviews with victims

and eyewitnesses, and in serious cases, a re-enactment of the incident can be undertaken

(Kelloway, 2011). In Jane's case, we conducted a walkthrough of the incident site and

interviewed Jane and Mr. Diaz. 

Observations/Walkthroughs:

At the start of the investigation process, we conducted a walkthrough at the incident site

to provide us with an overall picture of the environment (Kelloway, 2011). This information was

useful for identifying possible contributing factors, physical conditions, and work habits that

have contributed to the incident. During the walkthrough for Janes incident, we noticed that there

was limited space where the patient was transferred to. The patient's room was small and
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compressed with furniture such as the patient's bed, chair, and other operating machinery - such

as a vital machine, IV line, and an assistive device. The time of the incident occurred at 2100.

Lights are dimmed at 8pm in the patient’s room and there was also reduced daylight during the

time of the transfer. We also examined the mechanical lift machine and wheelchair that were at

the time of the incident; all in which were operating safely and correctly.   

Interviews:

Interviews are conducted during an incident investigation to obtain information from

eyewitnesses and victims that were present on the scene (CCOHS, 2020). We interviewed Mr.

Diaz and Jane separately two days after the incident occurred. Before the interview, both parties

were informed that the purpose of conducting the interview was to reduce possible injuries from

occurring in the future. The interviews took place in a private office to ensure the privacy and

confidentiality of staff and patients. During the interview, we let Jane and Mr. Diaz recall the

incident from their perspective by asking open-ended and necessary questions at appropriate

times. They were also asked to provide any feedback or questions that they had. At the end of the

interview, both Jane and Diaz were thanked for their valuable time and were also thanked for

helping with the investigation to prevent injuries in the long run. All information collected

during the interview was recorded promptly to support the investigation.

Analysis & Evaluation of Accident Using Investigative Tools

Once the walkthrough survey was conducted and interviews have been taken,

investigative tools are used to supplement the report. An investigative tool that was effective in

collecting information about Jane’s accident was to inspect record checks. Record checks contain

information of all employees and maintenance schedules of equipment (Kelloway, 2011). By

reviewing training records, it helped to evaluate if the worker was given proper instructions, if
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they were aware of safe methods of the task, and if they attended all training workshops and

signed the attendance sheet (Kelloway, 2011). Maintenance logs and records are also reviewed

as it provides information of potential hazards of the equipment, and if anything was conducted

to address these hazards (Kelloway, 2011). Maintenance logs provide detailed data of

preventative maintenance to predict future failures of equipment (Kelloway, 2011). The

maintenance logs were used to check the latest inspection of the ceiling lift in this case. The

ceiling lift has been regularly inspected and is safe to use prior to the incident. Next, Jane’s and

Mr. Diaz’s training records were reviewed. Attendance for orientation of safe transfers and use

of mechanical/ceiling lifts were reviewed. Jane’s records revealed she has three years experience

of transfers. However, Mr. Diaz’s training records revealed he has completed training sessions

but has minimal experience when using mechanical/ceiling lifts.

Another useful tool we used for the investigation was the use of computers. The use of a

computer helped us to document large amounts of information (Kelloway, 2011). It helped to

structure the entry of data into a secure database as well as allows portable access to the scene of

the accident (Kelloway, 2011). Aside from computers, if documenting on a computer is a hassle

to record information quickly during an interview process, a voice-recording device may be

useful for such situation.

Results and Future Recommendations

After a thorough investigation of Jane’s injury, the investigator found that Jane’s

testimony in her interview was backed up with inspection of Mr. Diaz’s training records. His

training records revealed that he had little experience with mechanical/ceiling lifts but has

completed all orientation and training sessions. The maintenance log for the mechanical lift

revealed it has gone through regular inspection and is in proper working condition. Hence, there
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was no possible failure of the equipment that would have caused Jane’s injury. In addition,

environmental factors contributed to the incident as inadequate lighting and space made it

difficult for both Jane and Mr. Diaz to perform a proper transfer. Going forward, Jane will have

to take sick leave as noted in her collective bargaining agreement as she waits for the approval

for worker’s compensation of benefits. Once contacted by WCB, they will notify her if she can

perform modified duties or apply for short-term disability. However, for short-term disability the

employer must provide the plan. If the plan is not covered, and Jane used up her sick leave, she is

eligible to apply for employment insurance (Financial Consumer Agency of Canada, 2018).

Furthermore, there are many ways to prevent this incident and other similar incidents

from reoccurring in the workplace. Future recommendations include: 

1. Minimize unsafe conditions:

o Declutter area - moving unnecessary equipment within the environment. For

example, vital machines can be removed from the patient's room and be kept at

the nursing station. In addition, moving assistive devices out of the way if they are

not being used.

o Ensure adequate lighting at all times, especially when transferring patients.

2. Training and Education Sessions:

o Additional training and education should be provided to employees such as:

 Mandatory e-learning modules.

 Mandatory in class, hands-on training on machines use in the facility.

 Mandatory refresher classes and e-learning modules – this can be done

every six months or annually.

 Mandatory orientation to all new and young employees on proper body

mechanics. 

3. Equipment Safety Checks:

o Conducting safety checks at the beginning and at the end of the shift by staff and

sign in a logbook.

o Specialists come to the facility every six months to ensure all mechanical lifts are

within working standards.

4. Staffing and workload distribution:

o Ensure adequate staffing and workload distribution is equal in the workplace.

 Research from Canadian Federation of Nurses Union shows in 2016 that

almost $2 billion was spent on nurses’ absenteeism and overtime due to

injuries and disabilities.

 Injuries and disabilities in the workplace, especially in healthcare can be

prevented with adequate staffing and equal workload distribution.

 Healthcare personnel should work without feeling burdened that they rush

their task to ensure all patients receive care or get hurt completing their

task within the allocated time they have.

Appendix A: Injured Worker’s Testimony of Accident

“I began my shift at 1530 and ended at 2330 on March 27th, 2020. My usual shift consisted of

caring and providing total care for 10 patients. Recently, there was a new team leader, Mr.

Andrew Diaz was assigned to the unit. According to Mr.Diaz, he finished his orientation two

days ago and was in his first shift working alone. My colleague and I oriented Mr. Diaz to the

unit patients, routines and schedules. At approximately 2100, Mr. Diaz called for assistance to

transfer a patient to bed. This patient was incapable of transferring independently due to his

condition and therefore required the both employees to use a mechanical lift to transfer him into

bed. Mr. Diaz had already prepared the machine and positioned the patient before I entered the

room. During the procedure, as we were operating the machine to transfer the patient, I noticed

that the patient was not secured in the machine and was falling off. I directed Mr.Diaz to stop the

machine and lower the resident back to his wheelchair to be repositioned with the harness. As the

patient was lowered down, he was not seated properly on the wheelchair and was about to fall on

the ground. Mr. Diaz and I prevented the patient from falling by carrying and lifting the patient

immediately back on the wheelchair with the use of our own power. The patient weighed

approximately 90kg and was uncooperative due to his fear of falling. After this event, I went to

finish my tasks and went home as scheduled. The next day I felt excruciating pain on my lower

back, radiating down to my legs. I was unable to call off work due to the timing, therefore I took

pain relievers instead. This was ineffective and I struggled to perform my tasks throughout my

shift. It has been two days since the incident occurred and the pain on my lower back is the same.

I continue to struggle with my daily tasks and cannot perform without taking pain relievers.”

 
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References

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