Safety Management System Occurrence Reporting

This chapter provides a brief summary of the root cause analysis process and will help you understand and conduct successful incident investigations. Incident investigation is an important element in an effective safety management system. The basic reason for investigating and reporting the causes of occurrences is to identify action plans to prevent recurrence of incidents. 

The fire tetrahedron indicates that if any of the elements is sufficiently reduced the propagation of the fire ceases and the full flame phase of the fire is prevented. One can envisage fire safety case reports using the fire tetrahedron as a basis, where for each operational mode of, for example, an off-shore fire management system, where the occurrence and significance of each tetrahedral element is judged to determine a level of risk priority. In turn each operational mode of a system is assessed to see if one or more of the four tetrahedral elements can be removed completely, or reduced to a level that would prevent fire propagation. 

An effective patient safety program cannot exist withont optimal reporting of medical or healthcare errors and occnrrences. The organization should adopt a no punitive approach in its management of errors and occurrences. Personnel must be able to report suspected or identified medical or healthcare errors without the fear of reprisal in relationship to their anployment. Organizations must support the concept that errors occur due to a breakdown in systems and processes. Improvement will be achieved by focusing on systems and processes rather than disciplining those involved in adverse events. 

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