Decisions made and actions taken in the first minutes and hours after an incident occurs in an aging services organization set the stage for everything else that follows. For instance, consider this hypothetical scenario:
A resident falls out of a lift, breaking a hip, but it is unclear what caused the fall. The lift is briefly checked by the staff involved, and they see nothing wrong, so the lift is not removed from service while the incident is investigated further. The next day, another resident falls from the same lift in a similar manner.