Blame, assigning

These four steps will result in the greatest positive effect when they are performed in an atmosphere of openness and trust. Management must demonstrate by both word and deed that the primary objective is not to assign blame, but to understand what happened for the sake of preventing future incidents. This book helps organizations define and refine their incident investigation systems to achieve positive results effectively and efficiently. 

Clearly focus on finding causes and management system weaknesses, and avoid assigning blame. 

Management must enforce a no blame policy once it is implemented. Once enforced, the system may need months or years to show results. Tremendous results can appear in just one year when management proves that they will not assign blame due to an incident. Building trust is the key. 

Investigators are not out to assign blame. Actions taken to blame and shame generally do little to prevent similar incidents from occurring. Therefore, it is necessary to foster an open and trusting environment where people feel free to discuss the evolution of an incident without fear of reprisal. Without such a supportive environment, involved individuals may be reluctant to cooperate in a full disclosure of occurrences leading to an incident and the incident investigation may be concluded prematurely with the root causes left uncovered. 

Management s charter to the team must include management s expectations for accurately reporting investigation outcomes. However, assigning blame or recommending disciplinary actions should not be part of a team s charter. 

In the simplest of such uses, attribution of risk is performed after a cancer has already occurred in order to assign blame or legal liability. Obvious examples have come finom attempts to attribute risks of cancer to previous radiation exposure, but others have also come from previous chemical exposures, e.g., in the case of leukemia following exposure to benzene. 

Since publication of the first edition I have become increasingly, painfully aware of just how short the half-life of certain Essentials can be in a field growing as quickly as is computational chemistry. While 1 utterly disavow any hubris on my part and indeed blithely assign all blame for this text s title to my editor, that does not detract from my satisfaction at having brought the text up from the ancient history of 2001 to the present of 2004. Hopefully, readers too will be satisfied with what s new and improved. 

Currently, many pharmacies have an ineffective approach to error reduction. Investigations that occur during the error reporting process tend to focus their attention on the front end or active end of the error such as the front-line practitioner (e.g., a technician preparing a prescription or a pharmacist dispensing the medication). Human nature tends to assign blame to these front-line practitioners involved in medication errors. It is easier and in our nature to blame individuals and resort to familiar solutions disciplinary action, individual remedial education, placing error information... 

Uses the FD-483 as measuring stick Priorities determined by regulatory authorities and resulting actions Assigns blame for failure Inability to obtain substantial and sustainable improvements... 

Every laboratory should have an internal accident-reporting system. This includes provisions for investigating the cause of an injury as well as any potentially serious incident that does not result in injury. The primary aim of such investigations should be to make recommendations to improve safety, not to assign blame for an incident. Local legal regulations may require reporting procedures for accidents or injuries. 

An excellent example of this is found in a study by Leape et al. (1995), which is referred to in greater detail in Chapter 12. The study found 264 preventable adverse drug events (ADEs) for which 16 major systems failures were identified as rmderlying causes of the errors. Of these 16 systems failures, 7 were responsible for 78% of the errors and were due to poor information systems. Thus, assigning blame to an individual or a certain procedure would have missed the cause entirely, which was likely the way that information was disseminated in the institution. Only by approaching the analysis from a systems perspective would it be possible to correct the real cause of the errors. 

Don t rationalize to the child or blame the school for the child s unwillingness to follow rules, to successfully socialize with other students, or to complete assigned work on time. 

Public opinion, in its single-minded assignment to industry of the blame for smog, was not completely off the mark. According to later estimates, emissions of organic gases from gasoline-powered vehicles in 1940 were... 

Admits it when problems crop up or help is needed Shares credit and does not assign blame Stays objective... 

The release of methyl isocyanate (MIC) from the Union Carbide chemical plant in Bhopal, India, in December 1984 has been called the worst industrial accident in history Conservative estimates point to 2,000 fatalities, 10,000 permanent disabilities (including blindness), and 200,000 injuries [38]. The Indian government blamed the accident on human error—the improper cleaning of a pipe at the plant. A relatively new worker was assigned to wash out some pipes and filters, which were clogged. MIC produces large amounts of heat when in contact with water, and the worker properly closed the valves to isolate the MIC tanks from the pipes and filters being washed. Nobody, however, inserted a required safety disk (called a slip blind) to back up the valves in case they leaked [12]. 

Assigning blame is necessary to learn from and prevent accidents or... 

Where does all this leave us There are two possible reasons for conducting an accident investigation (1) to assign blame for the accident and (2) to understand why it happened so that future accidents can be prevented. When the goal is to assign blame, the backward chain of events considered often stops when someone or something appropriate to blame is found, such as the baggage handler in the... 

Assigning blame is necessary to learn from and prevent accidents or incidents. Blame is the enemy of safety. Focus should be on understanding how the system behavior as a whole contributed to the loss and not on who or what to blame for it. 

If the objective of the accident analysis is to assign blame, then the different radio frequencies could be considered irrelevant because the differing technology meant they could not have communicated even if they had been on the same frequency. If the objective, however, is to learn enough to prevent future accidents, then the different radio frequencies are relevant. 

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