Incident Investigation

1. Incident Investigation Michael Lary, ARM-P, ALCM

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

3. Incident Investigation is NOT • A way to attach blame • A paper exercise required by someone

4. Incident Investigation is • Getting to the ROOT CAUSE

5. Getting to Root Cause

6. 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

7. 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.

8. 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

9. Hidden Costs Of Loss Medical DIRECT Indemnity Administrative Cost LostTime INDIRECT Lost Profits. Overtime Cost of Hiring and Training

10. 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

11. 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

12. 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

13. 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

14. 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

15. Four Causal Factor Areas Management Environment Employees Equipment

16. Incident Incident InvestigationAccident Sequence Direct Cause Contributing Cause Root Cause

17. Direct Causes • A sequence of unsafe acts and unsafe conditions that led up to the incident event

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

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

20. 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

21. Be Careful of Common Sense ?

22. 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.

23. Example 1 - MSI - OVER-REACHING

24. 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?

25. 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?

26. REMEMBER …. • Incidents are caused • Incidents can be prevented if causes are eliminated • The same incident will happen again if causes are not eliminated

27. 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

28. 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

29. Avoid Guessing

30. Take The Time • INVESTIGATE THOROUGHLY • INVESTIGATE NEAR MISSES • PREVENT FUTURE INJURIES

31. Using the Root Cause Form

32. QuestionsDiscussion