Accident investigations improve safety, Part 1
What a perfect world it would be if accidents never happened and we never had to think about it. But sadly, they do happen, and even more sadly, we often seem to accept them as a part of doing business.
Accidents do occur in long-term care. We know that. We also know that the Bureau of Labor Statistics recognizes long-term care as one of the highest-rated industries for occupational injuries. And be that as it may, we often seem all too willing to view these accidents as unavoidable, even before we know anything about them. And that is where our safety program breakdowns start to occur.
Over the years, I have asked a lot of managerial employees why they investigate accidents. The common responses:
- Exonerate individuals (or management);
- Satisfy insurance requirements;
- Defend a position for legal arguments; or
- Determine blame/responsibility.
Whenever an occupational accident occurs, a basic investigation is necessary. Through the investigation, we learn about causation, and we can put improvements in place to reduce the chances of recurrence. I’m not talking about occupational accidents that result in injury; I am talking about all occupational accidents. Even if any injury didn’t occur this time, a catastrophic injury from the same event may occur next time. Don’t wait for that to happen.
First and foremost, we must remind ourselves why we investigate accidents. Too often, I see my clients investigating accidents with what seems like a hidden agenda to place blame. It’s almost as if the mindset is: “something happened, and someone has to be blamed.”
Forget it. That doesn’t work.
FIND THE CAUSE
Accident investigations are done to identify contributing factors that led up to the event. The more we know about contributory causes, the better job we can do with our safety management program to lessen the chances of recurrence. Looking for that person to blame puts people on the defensive, resulting in a compromised investigation. When you create a culture that proves that your goal is to learn from every event to prevent a recurrence, then you already have won half the battle. Staff will be forthcoming, give honest answers and work with you to achieve the desired results.
First, what is an accident? In simple terms, I define an accident as “any unplanned and unwelcomed event that interrupts normal activity.” You will notice that I don’t talk about injuries or damages at all. That is an outcome of an accident, not an accident itself.
Imagine driving home from work, and you are stopped at a traffic light when the vehicle behind you fails to stop and runs into you. Was it unplanned? Sure. Was it unwelcomed? Did it interrupt your normal activity (driving home)? It sure did. Can it be called an accident? You bet.
ACCIDENTS AND OUTCOMES
Every accident has outcomes. We typically think of outcomes as negatives, but we can make them something positive as well. Negative outcomes include death and injury disease, damage to equipment/property, litigation costs and lost productivity.
On the other hand, accidents can have positive outcomes: the learning of new information; improvements to the safety programs; a demonstration of the organization's commitment to safety and a training/teaching opportunity, which improves morale.
It is often debated who is best suited to conduct the accident investigation. Many times, organizational leaders will turn to the safety officer, suggesting that such investigations are part of his or her job. Others will suggest that the administrator should assign someone to conduct the investigation, based on circumstances. As a safety professional, I believe that the person most qualified to conduct the initial accident investigation is the injured employee’s supervisor.
Typically, the supervisor will know the responsibilities of the position better than anyone else and will know the right questions to ask. And knowing the answers to the question in advance makes it much easier to conduct a more thorough investigation.
Every accident that occurs can be classified into one of three categories:
- Unsafe acts (human element),
- Unsafe conditions (environmental/design/structural) and
- Acts of God.
Once the event is categorized, it becomes easier to move the investigation forward. Look through old accident reports and see what was written as “factors” leading up to the accident. Often, I see what we call “attribution errors,” which usually are the result of trying to rush through an investigation, looking for the simplest and most obvious answers. Attribution errors typically look for someone to blame and use phrases such as:
- The employee is lazy.
- The employee lacks common sense
- The employee was inattentive.
- The employee was careless
- The employee is accident-prone.
- The employee should have known.
- The employee has a poor attitude.
Even if one or more of these statements are true, a thorough accident investigation will help to uncover reasons why the statement was made, and why it was true.
In Part 2 of this series, we will look at investigation strategies and “how tos.”
Until then, stay safe and stay in touch.
Steve Wilder, CHSP, STS, is president and chief operating officer of Sorensen, Wilder & Associates (SWA), a healthcare safety and security consulting group based in Bourbonnais, Ill. SWA performs workplace safety compliance audits and security vulnerability assessments in all types of healthcare facilities. Wilder can be reached at (800) 568-2931 or firstname.lastname@example.org.
Topics: Leadership , Risk Management