Critical incident reporting system

First, and most critically, many violations are in a sense invisible to those in the workplace. They know they happen, as we understood from interviews with railway shunters and anaesthetists, but on a daily basis they largely pass unnoticed so no one knows how often they occur. For these reasons, they do not feature in incident reporting systems, unless they have some serious consequence, which is very occasional. 

Along with incident reporting systems, hospitals should consider implementing After Event Reviews (AERs). InanAER, individuals discuss and provide feedback on critical events with the aim of detecting and learning from errors. Not ordy does this provide a forum to learn fiom errors, it also helps create a mindset that errors... 

Despite these many flaws in the official Incident Report system, the Region was able to identify and eorreet maity system safety deficiencies. Much of this success has been the result of the vigorous activity of the Regional Critical Incident Review Committee (RCIRC). As a Board of the Calgary Health Region designated (Quality... 

The critical incident technique was first described by Flanagan (1954) and was used during World War II to analyze "near-miss incidents." The war time studies of "pilot errors" by Fitts and Jones (1947) are the classic studies using this technique. The technique can be applied in different ways. The most common application is to ask individuals to describe situations involving errors made by themselves or their colleagues. Another, more systematic approach is to get them to fill in reports on critical incidents on a weekly basis. One recent development of the technique has been used in the aviation world, to solicit reports from aircraft crews in an anonjmrous or confidential way, on incidents in aircraft operations. Such data collection systems will be discussed more thoroughly in Chapter 6. 

The safety of the medication system is the primary concern of every hospital pharmacist. Recently published reports of the incidence, causes, and cost of injury resulting from medication errors have led many hospitals to critically evaluate their quality assurance systems (Bates et al., 1996, 1997 Classen et al., 1997 Kohn, Corrigan, and Donaldson, 1999 Leape et al., 1991, 1995 Poon et al., 2006 Stelfox, et al., 2006). Written incident reports were once the standard for gathering information about medication misadventures. This method is now believed to lack sufficient completeness and reliability for identifying weaknesses in a medication system (Classen et al., 1991 Cullen et al., 1995 Leape, 1994, 2002 Leape et al., 1995). 

As the body of professional risk expertise in organizations is often situated distant fiwm where the actual risks occur it seems reasonable to assume that the institutional context will affect risk reporting. The reason behind the present study indicated this The food and service company Compass Group Denmark experienced from time to time some critical incidents, hnt their risk reporting system failed to account for any risks prior to any of these incidents. In fact, risks were almost only reported under one of two conditions ... 

C.W. Johnson. 2003. Failure in Safety-Critical Systems A Handbook of Accident and Incident Reporting, University of Glasgow Press, http //www.dcs.gla.ac.uk/ jolmson/ book... 

The key section in Robens-style legislation is the duty of employers. Errrplqyers are reqnired to provide a work environment, plarrt and system of work which, so far as is reasonably practicable (the wording of this varies between jrrrisdictiorrs), do not preserrt a threat to the health and safety of employees. They must also consult with workers and provide adequate information, instruction and training, and report accidents of certain types (in some cases also critical incidents) to the relevant OSH authority. Employees are also subject to a number of duties which are enforceable in law. 

General The incident report provides an overall criticism of Statoils structure and systems. Specifically it appears that the barriers that were in piace to ensure safety were either misunderstood or ignored. 

Johnson, C. (2002). Software tools to support incident reporting in safety-critical systems. 

Amalberti cites the Aviation Safety Reporting Systran as an excellent example of a no-blame reporting system that generates over 60,000 reports per annum of mistakes made by air and ground crew, the vast majority of which did not result in incidents or near misses. If we are to study error, we need to study it in its context—for example, over 40% of all serious casualties occur at intersections. Let us study error at intersections with a view to providing controls to ensure errors don t lead to crashes or providing aids to decrease the likelihood of the safety-critical errors. There can be no doubt that solutions exist. 

Johnson C (2003) FaRure in safety-critical systems a handbook of accident and incident reporting. University of Glasgow Press, Glasgow... 

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