Learning from incidents – A method for assessing the effectiveness of the learning cycle

Improving Remedial Measures from Incident Investigations: A Study Across Ghanaian Mines

Background

Learning from incidents for accident prevention is a two-stage process, involving the investigation of past accidents to identify the causal factors, followed by the identification and implementation of remedial measures to address the identified causal factors. The focus of past research has been on the identification of causal factors, with limited focus on the identification and implementation of remedial measures. This research begins to contribute to this gap. The motivation for the research is twofold. First, previous analyses show the recurring nature of accidents within the Ghanaian mining industry, and the causal factors also remain the same. This raises questions on the nature and effectiveness of remedial measures identified to address the causes of past accidents. Secondly, without identifying and implementing remedial measures, the full benefits of accident investigations will not be achieved. Hence, this study aims to assess the nature of remedial measures proposed to address investigation causal factors.

Method

The study adopted SMARTER from business studies with the addition of HMW (H - Hierarchical, M - Mapping, and W - Weighting of causal factors) to analyse the recommendations from 500 individual investigation reports across seven different mines in Ghana.

Results

The individual and the work environment (79%) were mostly the focused during the search for causes, with limited focus on organisational factors (21%). Forty eight percentage of the recommendations were administrative, focussing on fixing the problem in the immediate affected area or department of the victim(s). Most recommendations (70.4%) were support activities that only enhance the effectiveness of control but do not prevent/mitigate the failure directly. Across all the mines, there was no focus on evaluating the performance of remedial measures after their implementation.

Conclusion

Identifying sharp-end causes leads to proposing weak recommendations which fail to address latent organisational conditions. The study proposed a guide for effective planning and implementation of remedial actions.

Exploring bias in incident investigations: An empirical examination using construction case studies

INTRODUCTION

Incident investigation is a foundational tool of safety management. Determining the causal factors of any incident underpins organizational learning and subsequent positive change to processes and practices. Research of incident investigation has largely focused on what information to collect, how to analyze it, and how to optimize resultant conclusions and organizational learning. However, much less attention has been paid to the process of information collection, and specifically that of subjective information obtained through interviews. Yet, as all humans are biased and can't help being so, the information collection process is inevitably vulnerable to bias.

METHOD

Simulated investigation interviews with 34 experienced investigators were conducted within the construction industry.

RESULTS

Common biases were revealed including confirmation bias, anchoring bias, and fundamental attribution error. Analysis was also able to unpack when and how these biases most often emerged in the interview process, and the potential consequences for organizational learning.

CONCLUSIONS

Being biased to a certain degree will remain inevitable for any individual, and therefore, efforts to mitigate the effects of biases is necessary.

PRACTICAL APPLICATIONS

Increased awareness and insights can support the development of processes and training for investigators to mitigate its effects and thus enhance learning from incidents in the field prevent reoccurrence.

From Anti-doping-I to Anti-doping-II: Toward a paradigm shift for doping prevention in sport

Doping remains an intractable issue in sport and occurs in a complex and dynamic environment comprising interactions between individual, situational, and environmental factors. Anti-doping efforts have previously predominantly focused on athlete behaviours and sophisticated detection methods, however, doping issues remain. As such, there is merit in exploring an alternative approach. The aim of this study was to apply a systems thinking approach to model the current anti-doping system for four football codes in Australia, using the Systems Theoretic Accident Model and Processes (STAMP). The STAMP control structure was developed and validated by eighteen subject matter experts across a five-phase validation process. Within the developed model, education was identified as a prominent approach anti-doping authorities use to combat doping. Further, the model suggests that a majority of existing controls are reactive, and hence that there is potential to employ leading indicators to proactively prevent doping and that new incident reporting systems could be developed to capture such information. It is our contention that anti-doping research and practice should consider a shift away from the current reactive and reductionist approach of detection and enforcement to a proactive and systemic approach focused on leading indicators. This will provide anti-doping agencies a new lens to look at doping in sport.

Incident reporting in the outdoors: a systems-based analysis of injury, illness, and psychosocial incidents in led outdoor activities in Australia

Incident reporting systems are a fundamental component of safety management, however, most systems used in practice are not aligned with contemporary accident causation models. This article presents an analysis of a National Incident Dataset (NID) for adverse incidents occurring in the Australian Led Outdoor Activity (LOA) sector. The aim was to investigate the adverse Injury, Illness, and Psychosocial incidents reported to the NID. In total, 1657 injuries, 532 illnesses, and 146 psychosocial incidents were analysed from 357,691 program participation days. The findings show that the rate of incidents per 1000 program participant days in LOAs was 4.6 for injury, 1.5 for illness, and 0.04 for psychosocial incidents, and incident severity was predominately minor. The analysis of systemic contributory factors demonstrates that incidents in LOA are systemic in nature, with multiple levels of the LOA system identified as contributing to adverse incidents. For example, contributory factors were identified across local government (facilities), schools (communication), parents (communication), LOA management (policies and procedures), people involved in the incidents (mental and physical condition), and the environment (terrain) and equipment (clothing). This study presents an assessment of the current state of safety in the Australian LOA sector and demonstrates the utility of applying systems ergonomics methods in practice. Practitioner summary: This article presents an analysis of 1657 injury, 532 illness, and 146 psychosocial incidents occurring in the Australian Led Outdoor Activity (LOA) sector, using a systems ergonomics method. The findings demonstrate the incident charactersitics and how decisions and actions from across the system contribute to adverse incidents in LOAs.

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure

OBJECTIVES

This study adopted a process view of organisational learning to investigate the barriers to effective organisational learning from medical errors.

METHODS

Qualitative data were collected from 40 clinicians in high and low performing hospitals. The fit between the organisational learning process and socio-technical factors was investigated systematically from a pre-reporting stage to reporting and post-reporting stages.

RESULTS

The analysis uncovered that the major stumbling blocks to active learning lie largely in the post-reporting stages and that they are rooted in social rather than technical issues. Although the experience of the higher-performing hospital provides valuable pointers in terms of creating more trusting environment and using the potential of small failures towards ways in which the organisational learning process in the lower hospital might be improved, due to lack of local mangers' proactive engagement in integrating changes into practice the active learning takes place in neither of the hospitals.

CONCLUSIONS

To ensure that the change solutions are firmly incorporated into the culture and routine practice of the hospital, we need to focus on fostering an organisational culture that encourages positive cooperation and mutual interactions between local managers and frontline clinicians. This process will lead to double-loop learning and an increase in system safety.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare

OBJECTIVE

A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

RESULTS

A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

CONCLUSION

Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

Applying a systems thinking lens to injury causation in the outdoors: Evidence collected during 3 years of the Understanding and Preventing Led Outdoor Accidents Data System

Introduction

This article presents a detailed systems analysis of injury incidents from 35 Australian led outdoor activity organisations between 2014 to 2017.

Method

Injury incident reports were collected using a specific led outdoor activity incident reporting system known as UPLOADS (Understanding and Preventing Led Outdoor Accidents Data System).

Results

In total, 1367 people sustained injuries from across 20 different activities, with an injury rate of 1.9 injured people per 1000 participants over the three-year period. A total of 2234 contributory factors from multiple levels of the led outdoor activity system were identified from the incident reports, and 361 relationships were identified between contributory factors.

Discussion

This systems analysis of injury incidents demonstrates that it is not only factors within the immediate context of the incident (Participants, Environment, Equipment) but factors from across multiple systemic levels that contributes to injury incidents (Schools, Parents, Activity centre management). Prevention efforts should focus on addressing the whole network of contributing factors and not only the prominent factors at the lower system levels within the immediate context of the injury incident occurrences.

Investigating the Maturity of Incident Investigations of the Ghanaian Mining Industry and Its Effect on Safety Performance

Effective incident investigations have been recognised as a vital means of improving safety. Nevertheless, there has been little attempt to link incident investigations to actual safety performance. In this study, a framework for assessing the maturity of incident investigations and identifying areas for improvements is described. The framework was developed based on a literature review and interviews with 41 investigators across five large-scale Ghanaian gold mines. The framework consists of 20 elements across four dimensions and five maturity levels. The dimensions (investigator competencies, system of investigation, stages of investigation and post-investigation findings) consider the most relevant aspects of practical investigation and for each dimension, elements that are more specific were defined across five maturity levels. Mapping the interview data collected from five mines into a maturity framework highlighted that the mines occupied different positions on the framework. Some occupied the advanced levels consistently and others consistently occupied the lower levels. Applying the interview data to the framework also identified priority areas for improvement. Finally, the maturity scores derived from mapping interview data onto the framework were correlated with the incidence rates of the mines to determine if any relationship existed between the two variables. The low incidence rate mines had higher maturity scores and the high incidence rate mines had lower maturity scores. It was found that the method was effective in practice, giving clear indications of areas where improvements are needed.

Rasmussen's legacy in the great outdoors: A new incident reporting and learning system for led outdoor activities

Jens Rasmussen's seminal risk management framework and accompanying Accimap method have become highly popular in safety science circles. Despite this, widespread adoption of the model and method in practice has not yet been achieved. This paper describes a project involving the development and implementation of an incident reporting and learning system underpinned by Rasmussen's risk management framework and Accimap method. The system was developed for the led outdoor activity sector in Australia to enable reporting and analysis of injuries and near miss incidents, with the aim of supporting the development of more effective countermeasures. An analysis of the data derived from the first 3 months use of the system by 43 organisations is presented. The outputs provide an in-depth Accimap-based analysis of all incidents reported by participating organisations over the 3 month period. In closing, the importance of developing usable domain specific tools to support translation of Ergonomics theory and methods in practice is discussed.

Workplace road safety risk management: An investigation into Australian practices

In Australia, more than 30% of the traffic volume can be attributed to work-related vehicles. Although work-related driver safety has been given increasing attention in the scientific literature, it is uncertain how well this knowledge has been translated into practice in industry. It is also unclear how current practice in industry can inform scientific knowledge. The aim of the research was to use a benchmarking tool developed by the National Road Safety Partnership Program to assess industry maturity in relation to risk management practices. A total of 83 managers from a range of small, medium and large organisations were recruited through the Victorian Work Authority. Semi-structured interviews aimed at eliciting information on current organisational practices, as well as policy and procedures around work-related driving were conducted and the data mapped onto the benchmarking tool. Overall, the results demonstrated varying levels of maturity of risk management practices across organisations, highlighting the need to build accountability within organisations, improve communication practices, improve journey management, reduce vehicle-related risk, improve driver competency through an effective workplace road safety management program and review organisational incident and infringement management. The findings of the study have important implications for industry and highlight the need to review current risk management practices.

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

Advocates of systems thinking approaches argue that accident prevention strategies should focus on reforming the system rather than on fixing the “broken components.” However, little guidance exists on how organizations can translate incident data into prevention strategies that address the systemic causes of accidents. This article describes and evaluates a series of systems thinking prevention strategies that were designed in response to the analysis of multiple incidents. The study was undertaken in the led outdoor activity (LOA) sector in Australia, which delivers supervised or instructed outdoor activities such as canyoning, sea kayaking, rock climbing and camping. The design process involved workshops with practitioners, and focussed on incident data analyzed using Rasmussen's AcciMap technique. A series of reflection points based on the systemic causes of accidents was used to guide the design process, and the AcciMap technique was used to represent the prevention strategies and the relationships between them, leading to the creation of PreventiMaps. An evaluation of the PreventiMaps revealed that all of them incorporated the core principles of the systems thinking approach and many proposed prevention strategies for improving vertical integration across the LOA system. However, the majority failed to address the migration of work practices and the erosion of risk controls. Overall, the findings suggest that the design process was partially successful in helping practitioners to translate incident data into prevention strategies that addressed the systemic causes of accidents; refinement of the design process is required to focus practitioners more on designing monitoring and feedback mechanisms to support decisions at the higher levels of the system.

From a reactive to a proactive safety approach. Analysis of medication errors in chemotherapy using general failure types

A better understanding of why medication errors (MEs) occur will mean that we can work proactively to minimise them. This study developed a proactive tool to identify general failure types (GFTs) in the process of managing cytotoxic drugs in healthcare. The tool is based on Reason's Tripod Delta tool. The GFTs and active failures were identified in 60 cases of MEs reported to the Swedish national authorities. The most frequently encountered GFTs were defences, procedures, organisation and design. Working conditions were often the common denominator underlying the MEs. Among the active failures identified, a majority were classified as slips, one‐third as mistakes, and for a few no active failure or error could be determined. It was found that the tool facilitated the qualitative understanding of how the organisational weaknesses and local characteristics influence the risks. It is recommended that the tool be used regularly. We propose further development of the GFT tool. We also propose a tool to be further developed into a proactive self‐evaluation tool that would work as a complement to already incident reporting and event and risk analyses.