Incident Reporting Systems

A number of researchers have highlighted the potential advantages associated with the collection and analysis of near-miss data. According to Reason (1997), the collection and analysis of near-miss data offer a number of advantages, including  

It is difficult to elicit information from actors who are involved in adverse incidents. 

The data obtained are subject to a number of biases, including confidence bias, hindsight bias, judgment bias, political bias, and recency bias. Incident reporting systems are typically expensive to set up and run. The ASRS, for example, spends approximately 3 million per year analyzing around 30,000 reports. 

Only limited sharing of data occurs between established incident reporting systems. 

Incident reporting systems may fail to keep actors in the loop. 

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In addition to incident reporting systems, root cause analysis techniques can be used to evaluate the causes of serious incidents where resources are usually available for in-depth investigations. A practical example of root cause investigation methods is provided in Chapter 7. 

Incident reporting systems, designed to identify underlying and direct causes for larger numbers of incidents with relatively minor causes... 

The main function of an incident reporting system (IRS) is to identify recurring trends from large numbers of incidents with relatively minor outcomes, or from near misses. One of the important characteristics of an IRS is that the time and resources required to evaluate an incident and incorporate it into the database must be minimized. This means that the designers of an IRS have to carefully evaluate the benefits and costs of requiring more comprehensive information from each incident that is to be reported. A requirement for too much information will bring the system into disrepute, and too little information will mean that the results are too general to be of any real value. 

In the first of the following subsections, the data coDection approaches adopted in most CPI incident reporting systems will be described. The fact that these systems provide little support for systematically gathering data on underlying causes will provide an introduction to the later sections which emphasize causal analysis techniques. 

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. 

These reports were in addition to the internal reporting for OSHA PSM and various local or state requirements. While Quality Chemical had long ago consolidated a number of these programs, there were still four different accident/incident reporting systems—one for external reporting of releases, one for external reporting of injuries and other nonrelease events, one for a corporate-wide database and one for each site itself. 

Reason J., 1991. Too little and too late a commentary on accident and incident reporting systems, in Schaaf van der, et al. (Eds.), Near miss reporting as a safety tool, Butterworth Heinemann, Oxford. 

Management of change Material safety data sheet Management systems verification National Association of Chemical Distributors North American Industry Classification System National Fire Incident Reporting System National Fire Protection Association National Institute of Standards and Technology National Oceanic and Atmospheric Administration National Response Center (USCG)... 

National Fire Incident Reporting System U.S. Fire Administration Reviewed only... 

Medication errors have been defined in many ways, depending on research methodologies, incident reporting systems, risk management, or total quality improvement systems. USP uses the broad definition of medication error from the NCC MERP ... 

Consider having one incident reporting system with one approach for teaching employees the definition of a near miss and with one approach for doing incident investigations including one approach for root cause analysis. 

Cullen DJ, Bates DW, Small SD, et al. 1995. The incident reporting system does not detect adverse events. Joint Comm J Qual Improv 21 541. 

This chapter starts with a discussion of the usefulness of incident reporting systems (of accidents and near misses) and then goes on to compare accidents versus near misses with the help of a qualitative iceberg model Next, three different purposes to collect and analyse such incidents are outlined. Finally, several methods to collect near misses in a variety of settings are presented. 

In short, it will be of paramount importance to ensure an optimal organisational in-bedding of the incident, reporting system. This means that the basic seven-step framework needs to be placed in a broader framework defining the life cycle of such an information system (Figure 4,4,),... 

The Navy lacks a comprehensive health incident reporting system. Some ad hoc systems may exist, but they will not serve either fleet or shore installation operations well in the event of a major chemical or biological attack. 

The role of incident reporting systems in HIT is still unclear from a practical perspective. Challenges remain in particular for ascertaining the precise role of technology in its contribution to an adverse incident, i.e. did it cause the event, fail to prevent it or simply remain a passive onlooker. Certainly the safety case should not be a replacement for sound incident reporting. But keeping a careful eye on local and national incident data will influence the hazards derived and the likelihood component of risk estimation. 

The reporting system now provides a way for operators of each nuclear power plant to reflect on their own operating experience in order to identify problems, interpret the reasons for these problems, and select corrective actions to ameliorate the problems and their causes. Incident reviews serve as important vehicles for self-analysis, knowledge sharing across boundaries inside and outside specific plants, and development of problem-resolution efforts. Both INPO and the NRC issue various letters and reports to make the industry aware of incidents as part of operating experience feedback, as does IAEA s Incident Reporting System. 

COMPUTERIZED ACCIDENT INCIDENT REPORTING SYSTEM (CAIRS)... 

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