Analysis of incidents

Analysis of Incident Root Causes Using the Sequential Error Model... 

For each of the stages of the model, Petersen (1985) provided a series of flow diagrams to assist analysts in using the model for incident analysis. These are given in Appendix 2B. The use of the model and the flow charts for detailed psychological analysis of incidents is illustrated by a case study in Appendix 2C. 

Detailed methods for incident analysis are described in Chapter 6. The methods described in this chapter provide the basis for a psychological analysis of incident causes. 

The personnel responsible for the collection and analysis of incident data vary in different organizations. One common practice is to assign the responsibility to an investigation team which includes the first line supervisor, a safety specialist and a plant worker or staff representative. Depending on the severity of an incident, other management or corporate level investigation teams may become involved. 

In the following sections, a number of methodologies for accident analysis will be presented. These focus primarily on the sequence and structure of an accident and the external causal factors involved. These methods provide valuable information for the interpretation process and the development of remedial measures. Because most of these techniques include a procedure for delineating the structure of an incident, and are therefore likely to be time consuming, they will usually be applied in the root cause analysis of incidents with severe consequences. 

Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001 29 1303-1310. 

Although the statistics provided in Section 3.3 concerning the number and severity of reactive incidents are grave, existing sources of incident data are inadequate to identify the number, severity, frequency, and causes of reactive incidents. The following limitations affected CSB analysis of incident data ... 

Each company s management style and safety systems have strengths and weaknesses. These strengths and weakness tend to influence the types and severity of incidents that might occur. An analysis of incident investigation findings in terms of causal factors, immediate causes, contributing causes,... 

Sudakin, D.L., Power, L.E. (2007). Organophosphate exposures in the United States a longimdinal analysis of incidents reported to poison centers. J. Toxicol. Environ. Health A 70 141-7. 

Ragaz J, Yun J, SpineUi J. Analysis of incidence of secondary acute myelogenous leukemias (2nd AML) in breast cancer patients (BCP) treated with adjuvant therapy (AT)-association with therapeutic regimens. (Abstract no. 147). Proc Am Soc Clin Oncol 1995 14 112. 

Hiesse C, Rieu P, Kriaa F, Larue JR, Goupy C, Neyrat N, Charpentier B. Malignancy after renal transplantation analysis of incidence and risk factors in 1700 patients followed during a 25-year period. Transplant Proc 1997 29(1-2) 831-3. 

Carson and Mumford, Analysis of incidents involving major hazards in the chemical industry. J. Hazard. Mai. 3, 149 (1979). 

The maintenance of facilities includes preventive maintenance programs that identify required preventive maintenance activities and recommended intervals based on safety, reliability, and economic considerations. Factors such as failure rate, replacement costs, impact on operations and safety, lessons learned, and analysis of incident causes are considered. Computerized programs provide for preventive maintenance schedules to be planned, implemented, and monitored. 

A method that applies in particular to fixed installations is one that is based on experimental feedback. Starting from an analysis of incidents by the method of event trees, it evaluates the probability that such events may degenerate into a serious accident, and by adding these probabilities over a period of time and referring the results to the number of installations of the same type, it can sometimes be shown that a serious accident becomes probable after a certain number of period trees (Savkovic-Stevanovic 2007, 2009, 2010 Savkovic-Stevanovic and Krstic 2006 Savkovic-Stevanovic et al. 2006). The importance of this method is that it is able to show that the safety of a system has become compromised even though no accident has occurred, and those responsible may believe that the system is operating satisfactory. 

We are now at a transitional point in the book between the understanding and analysis of incidents and the coining chapters, which discuss methods of prevention and quality improvement. The seven-levels framework has outlined the patient, task and technology, staff, team, working environment, organizational and institutional environmental factors that are revealed in analyses of incidents. These same factors also point to the means of intervention and different levels on which safety and quality must be addressed, which we will explore systematically as the book unfolds. 

We constructed an ontology that is a basis for systematic analysis of incident reports in healthcare based on P-mSHEL model. A conceptual design of an analysis system of incident reports has been proposed then for efficient processing of incident reports. 

Analysis of Incidence of Leukemia and Related Diseases.— The experimental data on the incidence of diseases of the blood and blood-forming tissues can be analyzed in the framework of the above treatment. However, because of the peculiar form in which the experimental results are presented ( Curve C percentage decrease in time to a 20 per cent incidence of reticular tissue tumors compared with the 20 per cent incidence time of the controls ), the analysis is subject to greater uncertainties and diflBculties and the data cannot so readily be evaluated statistically as those for the decreased life expectancy. We therefore content ourselves with a somewhat sketchy treatment, which should suffice to indicate the general nature of the problem. 

Busse, D. K., Wright, D. J., Classification and Analysis of Incidents in Complex, Medical Environments, Report, 2000. Available from the Intensive Care Unit, Western General Hospital, Edinburgh, U.K. 

Witters, D., Portnoy, S., Casamento, Ruggera, R, Bassen, H., Medical Device EMI FDA Analysis of Incident Reports, and Recent Concerns for Security Systems and Wireless Medical Telemetry, Proceedings of the 28th IEEE EMBS Annual International Conference, 2006, pp. 1289-1291. 

Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H (2007) Septic arthritis after arthroscopic anterior miciate ligament reconstmction a retrospective analysis of incidence, management and outcome. Am J Sports Med 35(7) 1059-1063. doi 10.1177/0363546507299443... 

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