Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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8 Checking for Biases in Incident Reporting
8 Checking for Biases in Incident Reporting
Pages 119-126
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From page 119... ...
In this paper, we define incidents as all safety-related events, including accidents (with negative outcomes, such as damage md injury) , near misses (situations in which accidents could have happened if there had been no timely md effective recovery)
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From page 120... ...
. This was sum, rising because this plant had been highly successful in establishing a reporting culture; minor damage, dangerous situations, and large numbers of near misses (i.e., initial errors and their subsequent successful recoveries)
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From page 121... ...
Based on our search, we concluded that, even though there is a relatively large body of literature on organiwhonal design guidelines for setting up incident reporting schemes, very few insights could be found into the reasons individuals decided whether or not to report an incident. We grouped the factors influencing incident reporting into four groups: · fear of disciplinary action (as a result of a "blame culture" in which individuals who make errors are pumshed)
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From page 122... ...
studied the likelihood of adverse events being reported by health care professionals and found that reporting is more common m places where protocols are m place and are not adhered to then where there are no protocols m place; m addition reports are more likely when patients were harmed; near misses, they found, are likely to go unreported. The suggested explanations for a reluctance or unwillingness to report are the culture of medicme, the emphasis on blame, and the threat of litigation, Probably the most comprehensive study so far, md to our knowledge the only one m which individuals were asked to indicate their reasons for not reportmg, was undertaken by Sharon Clarke (1998)
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From page 123... ...
, including how md when; describe the recovery action(s) taken; describe remaining actual consequences; md finally, "Would you have reported such an incident to the existing Near Miss Reporting System (choose from yes/no/maybe)
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From page 124... ...
In contrast, there were remaining consequences in a much higher percentage of the 50 events from the NMRS (involving multiple, different types of failures per event) : in six events a minor delay remained; in one event there were minor health-related consequences; in four events there were minor environmental consequences; in 14 events the hazard continued to exist for a significant time before the final correction was implemented; and in 20 events there were minor repair costs.
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From page 125... ...
Some of them had expected that there would still be some fear or shame about reporrmg self-errors and/or a low level of perceived potential consequences as the major reasons successful recoveries were not reported. Thus, the results showed a genume difference between operators and management m perceived importance, as measured by the options of no lessons to be learned, not appropriate for the system, full recovery, and no remaining consequences.
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From page 126... ...
Pp.127 136 in Near Miss Re pasting as a Safety Tool, T.W. van der Schaaf, D.A.
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