Why Investigate Safety or Quality-Related Incidents
An incident can be defined as an unplanned or undesired safety or quality-related event that adversely affects the completion of a task and may result in injury, property damage, or a disruption of progress.
The goal of incident investigation is to provide your organization with a holistic approach to continuously improve the safety and quality of your company’s operations. To achieve this, the focus of incident investigation should be to determine the underlying factors leading to the event and how to avoid future similar occurrences.
Incident statistics are lagging indicators. For example, an incident may fall into a category such as an injury, near miss, quality defect, etc. Lagging indicators tend to be easy to identify and measure (count). They may possibly be used to detect a trend or pattern of events.
By investigating the root or underlying cause(s) of such events, it is possible to find the leading indicators of incidents. Leading indicators tend to be more difficult to measure directly and rely on understanding the underlying cause(s) of such events. Investigating incidents to the level required to pinpoint the leading indicators can be challenging as it often draws our attention to items that require more energy and detail to resolve.
Cause(s) of safety and quality incidents tend to fall into three main categories:
System Design Weakness
- Missing or inadequate programs, procedures, or rules
- Lack of training programs
System Implementation Weakness
- Incomplete training (not conducted or fully understood)
- Inadequate supervision
- Inconsistent incident investigation
Lack of Care
- Culture/attitude
- Lack of enforcement or discipline
- Lack of updating procedures or training based on incident investigations
Investigations need to go beyond identifying the direct cause, and without placing blame, determine corrective actions to resolve the underlying conditions that led to such incidents.
For more information on how you can improve your investigations and risk control practices, please don’t hesitate to contact us.
