Incident Investigation trust

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. 

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. 

Senior management can and must, play a crucial role in this process. It is senior management that establishes expectation levels and fosters a climate of trust and confidence. It is also senior management that bears the responsibility for establishing a clearly defined process for incident investigations. 

A critically important skill for an auditor is interviewing. In particular, he or she needs to be someone who can ask open-ended questions and is a good listener. As discussed in Chapter 12 (Incident Investigation) the auditor should listen to what people actually say, focus on facts not opinions, and establish trust with the people they are talking to. 

The Guidelines for Investigating Chemical Process Incidents [4] has a section on near misses. Included in that section is a discussion of the fragile balance between a managers responsibility to promote and achieve near-miss reporting of incidents and the responsibility to discipline inappropriate behavior. It is a matter of trust and openness. A single occasion of necessary discipline (if viewed as somewhat unfair) can erode some confidence and create a... 

The risks are that IT failures may cause harm or deafiis and subsequent investigations and litigation. Experience with incidents would indicate fliat this is a real possibility to be taken seriously. There is an ever increasing dependence on IT and its infrastructure. The more successful it is the more it will be trusted, and the more responsibility there is on us to perform effective safety management on our IT systems. 

Your Trust s Risk Management Department (or similar) will deal with Sis. They ll inform you of an SI if you didn t already know, and guide you through the internal enquiry process. A panel will be formed which usually includes a Risk Management Department representative, an independent Trust consultant, and a non-medical health professional. An external investigation may take place if the incident s very serious (e.g. homicide), or the Trust s investigation is considered unsatisfactory. 

If your Trust offers Root Cause Analysis training, undertake it and apply the learning to minor incidents you spot in everyday practice. Remember, one day you may be the Si s investigating consultant, so this is all useful practice. 

The Trust will conduct a Serious Incident (SI) investigation, to understand why and how this happened, and prevent recurrence where possible (pl08)... 

The role of the team leader is to establish the analysis team, obtain consensus on the objective, and build trust and consistency in the analysis process. All type of fault finding must be eUminated and no fingers must be pointed. Copies of the standard operating procedures should be read before a team member investigating an incident. All results and recommendations must be based on facts, not opinions. 

Supervisors must possess the knowledge and experience to provide hazard control guidance to those they lead. First-line supervisors occupy a key hazard control position in many organizations. This position of trust can require supervisors to conduct area inspections, provide job training, ensure timely incident reporting, and accomplish initial accident investigations. 

---