Incident investigations should focus on change

Photo credit: andercismo on Flickr

Photo credit: andercismo on Flickr

The right approach to incident investigation – focusing on change not blame – is the way to better safety in future, say the organizers of Incident Investigations in Health Care and Social Services presented by WorkSafeBC on Tuesday, Jan. 29, 2013 in Richmond, B.C.

I wrote about this approach recently after reading about Incident investigations in health care: Focusing on change instead of blame.

The bulletin is intended for health care workers – but I see how its message can be applicable to others as well. I asked session organizer Jenny Colman to tell me more. She is a Human Factor Specialist/Ergonomist for WorkSafeBC’s Investigation Division, Incident Response Program.

“When incidents are viewed as personal failings, there may be no incident investigation beyond “don’t let that happen again,” she says. “To gain an understanding of why people do what they do there needs to be a thorough and systemic evaluation of the workplace.”

Such an evaluation may uncover systemic problems such as staff shortages, inadequate training, malfunctioning equipment, planning for the work, or the layout of the space.

“If the same set of circumstances are experienced by other workers it’s likely that they would make the same choices and take the same actions,” Colman said. “Ideally the person involved should be encouraged and supported to tell their story of the incident without blame or incrimination so organizations can learn from the event and make effective change in how the work is set up, planned and enacted.”

“It’s important to look beyond blaming an individual because change has a much greater level of safety benefit,” she said. “Taking a reprimand approach will only discourage the reporting of errors and incidents. It doesn’t solve the issues of why they occurred in the first place. Without effective change the same incident could occur again.”

Colman cites The Field Guide to Understanding Human Error – a book by Sidney Dekker, published in 2006 – as a source of ideas.

As I see it, the blame approach is a form of scapegoating workers – which is often a way to shift blame from managerial decisions that no one wants to own. What do you think?


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