Reporting Near Miss Incidents

Critical Incident Technique Personnel were asked to recall any incidents or near misses. This produced far more useful information for this study than the incident reports. 

It strongly supports reporting and investigating incidents and near misses, and emphasizes the value and necessity of communicating and sharing the lessons learned to all that could benefit. 

Management has the responsibility to create and maintain an atmosphere of trust and respect to encourage openness in reporting near misses and actual loss events. Failure to achieve this positive atmosphere will result in low or no reporting of near misses, which may ultimately lead to a catastrophic incident that could have been otherwise avoided. 

During facility operation, a chemical reactivity incident or near miss may occur despite all efforts to effectively manage chemical reactivity hazards. An essential element of managing chemical reactivity hazards is to appropriately report and investigate every incident or near miss involving chemical reactivity hazards. By investing the time and effort to determine the root causes and take corrective... 

Implementing a recommendation must go beyond an equipment, process or procedural change. What was learned about an incident or near miss and its causes, as well as the changes made to prevent recurrence, needs to be effectively communicated to employees. As a result, they will have a greater understanding to better identify future near misses and the factors that could lead to a chemical reactivity incident at their facility. This will also encourage employees to report other near misses. 

Encouraging employees to report all incidents including near misses... 

All operations and maintenance staff appropriate purchasing, accounting, and other staff Individuals who are expected to identify and report all incidents, including near misses. 

A witness may have several motives for purposely modifying statements. Witnesses have information that the incident investigation team needs in order to imderstand the incident and determine the causes. They may choose not to tell the incident investigation team all of the relevant information they have. Sometimes witnesses will purposely modify their testimony or withhold information during interviews. AVhat are some of their motives for doing this Usually they are the same as those for not reporting near misses. The most significant of these influences is fear of punishment. 

Trend analysis can be confused or invalidated by a sample that is too small. If the charting or analysis is limited only to major incidents, there will often be too few within a period to arrive at meaningful conclusions. For example, a facility with one thousand employees may experience only one or two serious incidents per year, and several years worth of data would be needed to make any meaningful statistical analysis. Minor incidents and near misses can be as useful in trend analysis and preventive prediction as major incidents. All process incidents should be reported, classified, and investigated as appropriate. The severity of an incident is frequently more a function of chance than actual fundamental system differences among accidents and near misses. 

The investigation of incidents identifies the specific root causes and contributing causes for incidents. There is less emphasis on identifying the specific individuals responsible. Disciplinary actions are rare but likely if there is a history of repeated occurrences. There is usually a greater amount of explanatory detail in the incident report. There is greater tendency in a fact finding organization to report near-miss as well as minor incident events. 

It was chosen and adapted to illustrate a combination of different types of causes- That is why its complexity, as shown in the Incident Production Tree later on, probably is somewhat higher than that of the average reported near miss. 

Commonly reported near misses include such events as exceeding operating limits, a release of a chemical or other hazardous substance that does not meet the threshold for a process safety incident metric, activation of relief valves, interlocks, or ruptured disks. Companies may establish near-miss metrics based on the specifics of their operation, based on their observations of frequent upsets or failures, or to track and correct observed unsafe practices or behaviors. 

Process safety improvement efforts will include performance goals that define the desired future state for the various elements of the process safety system. Examples may include 100-percent reporting of process safety incidents and near misses, 100-percent on-time completion of process safety training, and timely resolution for all hazards analysis recommendations. 

It is best to have a formal procedure for recording employee-identified hazards. This can be easily accomplished by a hazard form that provides a written record of the hazard, its location, and other pertinent information, such as the number of employees exposed and possible hazard-control measures. These forms can be distributed to each employee and be available from the department committee member. Employees may wish to express their views about the existence of potential hazards anonymously on the forms. Employees should report near-miss accidents, property damage incidents, and potential injury-producing hazards. It is essential in a program such as this that employees be given anonymity if desired and that they be assured that no action will be taken against them for their participation (even if they report silly hazards). 

I will report safety incidents or near misses in an objective, factual manner New employees report safety incidents or near misses in an objective, factual mannta ... 

Many would say that in the last 10 years a cultural revolution has occurred in healthcare delivery. Organisations in many countries are now more aware than ever of the potential for healthcare to cause harm. In response, most healthcare organisations have put in place measures to identify, report and manage adverse incidents and near-misses along with proactive risk control processes. The challenge for managers of these organisations is to extend this cultural awareness into the implementation of... 

The objective of risk management and a safety culture should be a proactive treatment of clinical risk and therefore minimisation of adverse incidents arising from HIT. Nevertheless this should not detract from the notion that one can learn a great deal from analysing incidents or near misses. A patient safety incident is an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient [22]. The ongoing study of incident reports can help identify common types of problems [23] and incident reporting has been cited as one of the major steps in improving the safety of HIT [24]. 

One of the most effective means of understanding and improving culture is to learn lessons from incidents and near misses such as the Warning Flags event just described. Such events show unequivocally that the facility culture did not operate effectively and that improvements need to be made. Evidence of a strong culture is the ratio of the number of reported near misses to the number of actual incidents in which someone is hurt, or the environment is impacted. A high ratio is evidence of a positive culture. 

One way of building a strong culture is to ensure that the employee who first reports an incident or near miss is kept fully informed as to the status of the follow-up actions, as should anyone who was injured in the event. Also, it is important not to make incident reporting too much of a hassle or too bureaucratic, otherwise people will not bother to use the system. 

A vital elanent of a safety management syston and a critical step in safety culture shift is a systan where anployees can report near-miss incidents without fear of repercussion. 

Number of reported near-miss incidents corrected... 

The biggest challenge to both leadership and employees is the declaration of safety amnesty, where employees feel free and confident to report and discuss safety issues no matter how sensitive they may be, without the fear of being victimized. Employees need to report near-miss incidents and other unsafe situations without repercussion so that these can be rectified. A mutual trust must be developed between management and employees, and joint communication safety committees are vital for this purpose. 

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