In 2002, the Risk Management Task Force recommended that post-incident reviews be conducted in order to avoid or reduce losses or incidents in the future.

Pursuant to RCW 43.19.782, all state agencies are to appoint a Loss Prevention Review Team when the death of a person, serious injury to a person, or other substantial loss is alleged or suspected to be caused at least in part by the actions of a state agency except when the death, injury or substantial loss is already being investigated by another federal or state agency.

The Department of Enterprise Services may also direct a state agency to conduct a loss prevention review and, if requested, may provide guidance to a state agency conducting a loss prevention review. Loss Prevention Review Team program requirements, including reporting requirements, are provided in RCW 43.19.782 and RCW 43.19.783.

Loss prevention review team

• Consists of at least three person and may include independent consultants, contractors, or state employees.
• Does not include any person directly involved in the loss or risk of loss giving rise to the review, nor any person with testimonial knowledge of the incident to be reviewed.
• At least one member of the review team shall have expertise relevant to the matter under review.
• No more than half of the review team members may be employees of the affected agency.
• Provides a written report to the Director of DES and the head of the state agency involved in the loss or risk of loss upon completion of their review.  These reports are posted to the DES website.

Incident reporting

The LPRT Program Requirements include criteria for determining which incidents are to be reported to DES. When an incident meets these criteria, agencies will report them to DES using the Incident Report Form and email the form to DESRMIncidentReporting@des.wa.gov. The DES Loss Prevention Program reviews all incident reports, enters them into the claims database, and reviews them to determine whether an LPRT should convene.

Resources

• The Loss Prevention Review Team Toolkit contains information and templates to use when conducting a review.
• DES Risk Management can provide Root Cause Analysis training or facilitate a root cause analysis session.

Questions

For questions about the reporting guidelines, the review process or other aspects of this program, contact Jason Siems, State Risk Manager at 360-407-8729 or Jean Jelinek, Loss Prevention Program Coordinator at 360-407-8158.