Understanding Accidents

Accidents result from a single or primary cause. 

Accidents must generate injury or property damage. 

Accidents occur when random variables interact. 

Accident prevention requires the comprehensive analysis of accident and injury data to determine types of events, severity of injuries, and trends within specific units or the entire organization. 

The prevention of accidents must include process innovations such as machine guarding, use of warning signs, requiring use of PPE, providing real-world safety education and training sessions, and developing adequate administrative policies or 

We can simply define an accident as an unplanned event that interferes with job or task completion. When an accident occurs, someone will lose valuable time to dealing with the event. An accident can result in some kind of measureable loss such as personal injury or property damage. An accident event can also be classified as a near miss with no measurable loss. Accident causes normally result from unsafe acts, hazardous conditions, or both. Accident prevention efforts must emphasize the importance of developing necessary policies, procedures, and rules. The hazard control plan should outline organizational objectives, goals, and responsibilities. The organization needs to evaluate the priority and effectiveness of accident-prevention efforts. 

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Assumption 2 Accidents are caused by chains of directly related events. We can understand accidents and assess risk by looking at the chain of events leading to the loss. 

Encourage a shift in the emphasis in accident analysis from cause —which has a limiting, blame orientation—to understanding accidents in terms of reasons, that is, why the events and errors occurred [197]. Learning how to engineer safer systems is the goal here, not identifying whom to punish. 

To understand the dynamic aspects of accidents, the process leading to the loss can be viewed as an adaptive feedback function where the safety control system performance degrades over time as the system attempts to meet a complex set of goals and values. Adaptation is critical in understanding accidents, and the adaptive feedback mechanism inherent in the model allows a STAMP analysis to incorporate adaptation as a fundamental system property. 

The goal of STAMP is to assist in understanding why accidents occur and to use that understanding to create new and better ways to prevent losses. This chapter and several of the appendices provide examples of how STAMP can be used to analyze and understand accident causation. The particular examples were selected to demonstrate the applicability of STAMP to very different types of systems and industries. A process, called CAST (Causal Analysis based on STAMP) is described in chapter 11 to assist in performing the analysis. 

This chapter focuses on safe practice in relation to educational activities and experiences that take pupils away from the school and into the outdoor classroom. Here, the complex interplay of human and environmental factors is a significant issue and one which differentiates the learning context from that found on the school site and within the classroom. Drawing on case studies and research on accidents in the outdoors, this chapter begins by considering the unique nature of the outdoor classroom and what can be learned from tragedy in terms of understanding accidents in the outdoors. It also identifies supervision as the basic principle of safe practice and discusses elements of this and the... 

Deming believed that statistical methods should be used as a guide to understanding accidents and to their reduction. The following is quoted from Out of the Crisis on reducing accident frequency ... 

In daily life, errors are frequently attributed to stupidity, carelessness, forgetfulness, recklessness and other personal defects. The implication is that the person who makes an error has certain characteristics which produce the error and, furthermore, that these characteristics are under their control and they are therefore to blame for the errors they make. This is error seen from the individual perspective when applied to understanding accidents James Reason refers to this as the person model (Reason, 2000). 

Among the significant contribntions that the field of human factors makes to understanding accidents in health care is the notion that the conditions in which human beings work must be altered. 

Hollnagel, E. (2002). Understanding accidents - from root causes to performance variability. Proceedings of the IEEE 7th Human Factors Meeting, (pp. 1.1-1.6). Scottsdale Arizona, 2002. 

Explain the benefits of understanding accident causation theory... 

What are some of the benefits associated with understanding accident causation theory Explain your answer. 

Examining the concepts and principles of patient safety as related to organizational dynamics, culture, system methods, and key patient safety initiatives, the book supplies essential knowledge of healthcare safety risks, challenges, and controls. It includes information on leadership, management, communication skills, and understanding accidents. 

In aviation, the taxonomy called Human Factors Analysis and Classification System (HFACS) has been established see Shappell Wiegmann (2000), to understand accidents based on several factors than mere human error. The HFACS taxonomy are based on the Swiss Cheese Model from Reason (1997), looking at accidents as unsafe acts based on preconditions, unsafe conditions and organisational influences, in order to avoid blaming the human element. However, the HFACS method has no exploration of resilience, and should be extended to cover resilient acts, based on preconditions of resilience, resilient conditions and High Reliable Organisational influences. 

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