Near miss investigation systems

With so much information and work that has culminated in this book, numerous people need to be thanked. I would like to thank the industrialists and miners that I have dealt with over the past 38 years. I learned industrial safety from them and a great deal about near miss incidents from their near miss investigation systems and from their experiences in dealing with the aspect of safety in the shadows. ... 

Part of my role as safety advisor was to train the safety teams in all aspects of the system so that they were competent to implement and coordinate it in their own areas of responsibility. I also assisted in developing the newly redesigned safety team and taught them accident and near-miss investigation techniques, risk management, and other safety system-related courses. 

Safety authority is the total influence, rights, and ability of the position to command and demand safety. Management has ultimate safety authority, therefore, is the only echelon that can effectively implement and maintain an effective near miss incident system. Leadership has the authority to demand the reporting and investigation of near miss incidents and also the authority to take necessary remedial actions to prevent recurrences of the event. 

Managanent at all levels is then held accountable to rectify the problems identified by the near miss investigations and to ensure that the high risk acts or conditions highlighted by the system are rectified and do not recur. 

The following document is an example of an organization s near miss incident system standard that describes the organization s commitment to near miss incident reporting and investigation, and also clearly spells out responsibilities. 

For the system to succeed, it is important to note that all the events reported cannot, and should not, be subject to a full near miss investigation process. This will bog the investigators down and prove too time consuming. 

It is often difficult to make a determination whether a specific event is a near miss or a "nonincident" (neither an actual loss event nor a near miss). If the users of the investigation system do not identify an event to be at least a near miss, then the event will not be investigated and valuable lessons may be lost. Depending on the definition of a near miss, roughly 50 to 100 near misses occur for every actual loss event and 50 to 100 precursors for every near miss. Figure 4.6 depicts the general relation between precursors, near misses and loss events. 

Note that near misses (Chapter 5), human factors (Chapter 6), and legal issues (Chapter 12) are special considerations in both preplanning and deploying the incident investigation management system. 

A related fallacy is if a company trains enough investigators, near misses will be reported so there is no need to establish a blame-free system. This assumption has been proven false when fear of blame is not addressed. 

An apparently high level of effort is required to report and investigate near misses. The costs of this effort are quantifiable. The benefits of these investigations are not as easy to tabulate. The actual number of accidents that have been prevented by improved near miss reporting may never be known. However, organizations that have seen dramatic increases in near miss reporting have also seen dramatic reductions in losses. The root causes of near misses of safety consequences may be the same management system weaknesses that adversely affect operability, quality, and profitability. 

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. 

Investigation and follow-through of accidents and near misses shows the intent by the company to discover and correct problems in the system. However, investigations without follow-up may be perceived as a demonstration of neglect by company management. 

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. 

Lucas (1992) proposes that different safety cultures will have an impact on which accidents are investigated and whether or not near miss reporting is perceived as a valuable use of resources an occupational safety culture would probably investigate only serious personal injuries the risk management culture might be interested in certain types of near misses with very direct and serious potential safety consequences finally a systemic safety culture will encourage its employees to report anything related to possible deviations, either with immediate or delayed consequences for safety control. 

Percentage of near-miss and incident investigations identifying RBPS management system weaknesses that were not detected by prior audits X... 

Thus, the process-improvement approach to the safety of the medication-use cycle goes beyond the celebrated cases and first stories to scientifically investigate the system as a whole. Data on near-misses and uncelebrated errors should be analyzed to find hidden flaws and strengths, and to better understand the dynamics of our medication-use system. Scientific investigation of the whole cycle— peeling away the layers of the onion—will reveal latent points of failure and facilitate a redesign that substantially reduces the occurrence of harmful outcomes. 

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many incident analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again. 

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