Data collection incident reporting systems

The amoimt of time available for the recording of data in incident reporting systems is limited, and hence the information collected is usually confined to short descriptions of the event, its actual and potential consequences and... 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

Once you have a system that captures, accurately, over 30% of your real electrical contacts (i.e., near misses, incidents and accidents) you may be able to develop a system for fixing the causes. Preventive safety, not data collection and report writing, must be the reason for a safety reporting system. 

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 types of data required for incident reporting and root cause analysis systems are specified. Data Collection practices in the CPI are described, and a detailed specification of the types of information needed for causal analyses is provided. 

Emphasis for prevention will be on changing individual behavior by symbolic or tangible rewards based on statistical evidence from the data collection system. "Hard" performance indicators such as lost time incidents will therefore be preferred to "softer" data such as near-miss reports. Accident prevention will also emphasize motivational campaigns designed to enhance the awareness of hazards and adherence to rules. If a severe accident occurs, it is likely that disciplinary sanctions will be applied. 

Besides regulatory development and enforcement, other OPS functions include pipeline safety data analysis based on data collected by OPS through annual and incident reports from the industry and from OPS inspections of pipeline systems, sponsoring of research, and training. 

Reporting System Control Centers collects data from individual centers on over 150,000 poisoning incidents annually... 

Aeronautics and Space Administration (NASA) for the aviation industry. NASA, external to the industry, accepts confldential narratives about near misses and accidents up to the point of a crash (Reynard, Billings, Cheaney, and Hardy, 1986). The system is voluntary, confidential, and nonpunitive, and its purpose is to collect and use incident data to improve the national aviation system. The ASRS supports aviation system policy, planning, and improvement and strengthens the foundation of human factors research in aviation by identifying deficiencies for correction by appropriate authorities. The Veterans Administration is the only health care entity to contract with NASA for a blameless reporting system at this time. 

One test of the efficiency of a data collection system is whether near-miss incidents are reported and recorded. Their investigation will provide the same information on causation as real injury incidents. 

To identify opportunities for reducing medication errorS/ it is important that each error be carefully reviewed by a limited number of individuals to gain intimate knowledge of each reported incident. Collection and classification of error data must be followed by use of a careful epidemiological approach to problem solving at the system level. Narrative data which may not be seen by looking at the categorical data alone/ can be used to provide important details about proximal causes and latent error that may have contributed to the event. Success in this type of error reduction requires the reviewers to read between the lineS/ look for common threads between reports/ and link multiple errors that are the result of system weaknesses. 

IMCA collects, analyzes, and shares data on industry incidents from work in offshore construction. One key system for distributing the data is an alert called a safety flash. Safety flashes are developed from reports submitted to IMCA and contain descriptions of incidents, near misses, and potential hazards. The reports also give the apparent cause (or causes) of the incident and any actions taken to prevent a recurrence. Before it is distributed publicly, a safety flash is stripped of identifying information and is sent to the contributing company for its approval. ... 

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