Incident investigation
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Incident Investigation. Michael Lary, ARM-P, ALCM. Incident Investigation Purpose. The primary purpose of an Incident Investigation is to learn Incident causes and prevent recurrence. Incident Investigation is NOT. A way to attach blame A paper exercise required by someone.

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Incident investigation

Incident Investigation

Michael Lary, ARM-P, ALCM


Incident investigation purpose

Incident Investigation Purpose

The primary purpose of an Incident Investigation is to learn Incident causes and prevent recurrence.


Incident investigation is not

Incident Investigation is NOT

  • A way to attach blame

  • A paper exercise required by someone


Incident investigation is

Incident Investigation is

  • Getting to the ROOT CAUSE


Getting to root cause

Getting to Root Cause


What is root cause

What is Root Cause

A method of determining why things occur by questioning why things are done the way they are or why they occurred


Root cause 5 whys method

Root Cause - 5 Whys Method

Best Practices USED BY:

Lean Methods

Six Sigma

Toyota Motors

Software Debugging

Quality Healthcare Groups

Amazon.com

WA Hospitals

Leading Quality Organizations

Accident Investigators

Aircraft Manufacturers

Computer Manufacturers

And others

WHWCP has developed it’s own

Root Cause Form which we will

Cover during this class.


Why take time to do an incident investigation

Why Take Time To Do An Incident Investigation

  • To prevent future occurrences of similar Incidents

  • To show concern from management for the employees

  • Insurance costs are not a fixed expense

  • Required by law, regulation, Hospital and Trust policies


Hidden costs of loss

Hidden Costs Of Loss

Medical

DIRECT

Indemnity

Administrative Cost

LostTime

INDIRECT

Lost Profits.

Overtime

Cost of Hiring and Training


How it all starts

How it all Starts

  • Employee has an incident

    • Obtains First Aid

    • Seeks Medical Treatment

    • Completes the Employee Report of Incident

  • Reports it to supervisor

  • Supervisor Completes their report


Who investigates

Who Investigates

  • WAC 296-800-32020 states that the preliminary investigation for serious injuries must include:

    • Person designated by employer

    • Immediate supervisor of injured worker

    • Witnesses

    • Employee representative (union or elected safety committee member)

    • Any other person with experience and skills


When how what

When, How, What

  • WHEN - ASAP, or when conditions safely permit

  • HOW - Isolate area, locate and interview witnesses, interview injured worker

  • WHAT - Serious injuries, minor injuries, near misses, property damage


Why supervisors investigate

Why Supervisors Investigate

  • Trained the employee

  • Supervise work habits

  • Responsible for safe methods and conditions

  • May be in constant contact with the employee and most familiar with work involved

  • Most familiar with available corrective actions


Investigation techniques

Investigation Techniques

  • Put person at ease

  • Emphasize fact finding

  • Conduct a private interview

  • Ask open not leading questions

  • Verify what is said

  • Explore all the clues

  • Get all sides of the story

  • If re-enacting - use caution


Four causal factor areas

Four Causal Factor Areas

Management

Environment

Employees

Equipment


Incident investigation accident sequence

Incident

Incident InvestigationAccident Sequence

Direct Cause

Contributing Cause

Root Cause


Direct causes

Direct Causes

  • A sequence of unsafe acts and unsafe conditions that led up to the incident event


Contributing causes

Contributing Causes

  • The reasons “Why” the Direct Cause(s) were allowed to occur, or failed to occur


Root cause

Root Cause

  • Controls which allowed the existence/ occurrence of the Contributing cause(s) and allow them to exist elsewhere


Root cause analysis

Root Cause Analysis

  • Describe Incident

  • Ask about preceding events

  • Ask why each cause was allowed to exist

    • Ask WHY five time to get all issues addressed

    • Review four casual factor areas

  • Use the checklist on the RC form


Be careful of common sense

Be Careful of Common Sense ?


Investigations summary checklist

INVESTIGATIONS… Summary Checklist

  • Immediately review the incident report once received

  • Remove any immediate hazards or dangers that have the potential to cause injury

  • Initiate the Investigation process ASAP

  • Immediately follow-up on recommendations made and implement corrective measures

  • Ensure corrective measures are effective in preventing a similar repeat incident in future

  • Ensure the Accident and Injury report form is complete, signed off and forwarded as indicated

  • If you have questions or concerns about the Investigation process contact a Safety Advisor in your service area.


Example 1 msi over reaching

Example 1 - MSI - OVER-REACHING


Example 2 chemical burn

Example 2 - Chemical Burn

When investigating a Chemical Burntype injury some questions that can be asked are:

  • Was the right chemical being used for the right purpose?

  • Is the MSDS current and readily available?

  • Was Personal Protective Equipment worn as specified? (i.e. gloves)

  • Are there safe work procedures written for the safe use of the chemical?

  • Does the worker have adequate HAZCOM training?


Example 3 slip trip fall

Example # 3Slip/Trip Fall

  • When Investigating a Slip/Trip type injury some questions that can be asked are:

    • What was the tripping hazard?

    • What immediate action needs to be taken?

    • What can be done to ensure the tripping hazard is dealt with over the long term?

    • Who needs to know any new information resulting from the investigation?


Remember

REMEMBER ….

  • Incidents are caused

  • Incidents can be prevented if causes are eliminated

  • The same incident will happen again if causes are not eliminated


Corrective actions can include

Corrective Actions Can Include

  • Holding employees and supervisors accountable for safety

  • Improving supervisor/employee communication

  • Improving guards, signs, warning lights

  • Developing and implementing safety policy and procedures


Incident investigation summary

Incident Investigation Summary

  • Understand the critical importance of incident investigation and reporting

  • Use tools presented in this course to determine root causes and corrective actions

  • Understand the importance of corrective action/follow up


Avoid guessing

Avoid Guessing


Take the time

Take The Time

  • INVESTIGATE THOROUGHLY

  • INVESTIGATE NEAR MISSES

  • PREVENT FUTURE INJURIES


Using the root cause form

Using the Root Cause Form


Questions discussion

QuestionsDiscussion


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