Incident Reporting and Investigation Getting to the Root Cause SASWH

Incident Reporting and Investigation Getting to the Root Cause SASWH Rev. Jan 2, 2018

Housekeeping Details

Workers and Patients Worker incidents Patient/Client/Resident incidents Both have legislation, rules, forms and paperwork Same goal Same investigative steps

Learning Objectives By the end of this workshop you will be familiar with: Regulatory requirements for reporting, investigating and reviewing workplace incidents and dangerous occurrences Elements of an effective workplace incident reporting and investigation program Be able to explain and apply the incident investigation process to: Collect evidence for an investigation Analyze evidence for an investigation Determine the contributing factors and root causes(s) of the incident Develop a report listing recommendations for corrective actions Ensure follow-up of recommendations PRE-COURSE ASSESSMENT Back Page

Introduce Yourself Your name Where you work Why are you here? – Are you on an OHC? – Are you a Supervisor? What involvement have you had or will you have in a workplace investigation?

About This Course Unsafe Behaviour Hazardous Conditions Able to Prevent Uncontrollable Acts

This workshop is 5 modules Introduction Effective incident reporting and investigation programs Regulatory requirements Investigation techniques Reporting, recommendations and follow-up Please follow along in your workbooks

Definitions Accident: Incident: Not defined in legislation An unwanted, unplanned event that results in a loss (production, property or human) – SASWH SMS Not defined in legislation An unwanted, unplanned event that results in or could have resulted in a loss (production, property or human) – SASWH SMS Standards 2012 Often also refers to a near miss Standards 2012 Dangerous Occurrence: Defined in Regulation 9 Basically, any incident that could have injured, hospitalized or caused the death of a worker, but didn’t Adverse Event Unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. The Canadian Patient Safety Dictionary Page 1

Reasons for Investigating Prevention The law Due diligence Demonstrate commitment Best practice Hazard identification and control Page 2

Human Factors Limitations of Human Performance 1. 2. 3. 4. 5. 6. 7. Limited short term memory Running late / in a hurry Limited ability to multi-task Interruptions Stress Fatigue (and other physiological factors) Environmental Factors Lessons From Human Factors Research 1. 2. 3. 4. 5. 6. Reduce reliance on memory Reduce reliance on vigilance Simplify tasks and processes Reduce handoffs Reduce need for calculation Provide for reversibility or automatic correction 7. Plan for recovery when prevention fails 8. Provide adequate training 9. Manage fatigue 10. Provide adequate informational resources at point of care

Organizational Error Chain System Approach Latent Conditions arise from decisions made by designers, procedure writers, management – understaffing, fatigue, inadequate experience or equipment Active failures are unsafe acts - slips, lapses, fumbles, mistakes, and procedural violations

Incident Reporting Standards Provincial SMS Standard 5.1 Reporting processes for: – Hazards/concerns – Incidents – Property/equipment damage – Near misses Employees must know how to report Managers must encourage employees to say something when they see unsafe conditions/behaviours Managers must stop work if the task is unsafe Corrective actions to address reported hazards/concerns must be identified Corrective actions to address reported hazards/concerns must be implemented There must be defined processes for reporting to regulators Page 2

Incident Investigation Standards Provincial SMS Standard 5.2 Defined investigation processes that assign responsibilities Investigations must be conducted for: – Hazards/concerns – Incidents – Property/equipment damage – Near misses The OHC must investigate: – Serious accidents – Dangerous occurrences – Work refusals Employees must be trained Corrective actions must be prioritized according to risk Corrective actions must be implemented by the target dates Results of investigations must be communicated A standardized incident investigation form must be used Page 2

Incident Reporting and Investigation Program Policy statement – Responsibilities Incident reporting process – What, when, how, to who, why – Record keeping and statistics Root cause investigation process – What, who, when, how, why Reporting and follow-up Training Page 3

Employer’s Role The employer is responsible for: Assuring that the incident investigation process is included in the SMS The effectiveness of the investigations Correcting identified problems Providing investigators with appropriate time, training and resources Management/Executive Monitor the Incident Reporting and Investigation process for their respective areas of responsibility Page 4

The Supervisor’s Role Promptly initiate the investigation Involve others as required as per internal procedures and external requirements Ensure that appropriate control measures are implemented Monitoring and evaluate the effectiveness of the controls

Worker’s Role Report all incidents as per policy Completion of the Incident Report form; Cooperate during the incident investigation process Participate in an incident investigation as required

OHC Role Investigate all dangerous occurrences, serious injuries and fatalities as required by OH&S legislation Participate in other investigations at the request of the supervisor or as defined in the local OHC Terms of Reference Review the incident reports and investigations for select incidents Monitor the employer’s health and safety management system * Worker incidents only ** Implementing corrective action is the employer’s responsibility

The Investigation Team In most cases the Supervisor should investigate the event Other members of the team could include: Employees with knowledge about the work and process involved OHC member(s) or representative Other employee(s) with training in investigations The internal health and safety advisor An outside expert (ergonomist)

Benefits of Worker Involvement More effective investigations Improved credibility Improved acceptance of recommendations Conducting investigations is an important function of the OHC/OH&S Rep Page 4

Training Training ensures the members of the investigating team know what to do and are able to determine the root causes of the event. Training should include how to: Collect evidence Interview witnesses Analyze the facts Make recommendations Page 5

Forms Provide order, consistency and completeness Part of a documented program/process Checklists ensure nothing is forgotten or overlooked Suggested forms are referenced in the workbook Separate reporting form for worker incidents and patient incidents Page 5

Investigation Kit Appropriate forms and checklists Floor plans, diagrams or maps of the workplace Camera Flashlight Emergency phone numbers and other useful contacts Tape measure Required PPE for investigating Pencils, pen, paper * Contact OH&S Department as required Page 5

Regulatory Requirements Reporting, Investigating, Reviewing

OH&S Summary LRWS Reportable Incidents Review Required Investigation Required LRWS Labour Relations and Workplace Safety Page 6 Page 20 - 22

Incident Scenario

Determine the legislated requirements for the Incident Scenario In your groups go to page 23 and answer the OH&S Legislated Requirements questions

Investigation Techniques

Domino Theory "The occurrence of an injury invariably results from a completed sequence of factors, the last one of these being the accident itself. The accident in turn is invariably caused or permitted directly by the unsafe act of a person and/or a mechanical or physical hazard.“ (W.H. Heinrich, Industrial Accident Prevention, 1931)

Degree of Investigation Depends on: – Internal workplace policies – An Occupational Health Officer may also request further investigation Risk analysis: – How many workers could be affected by a repeat similar occurrence? – Is this incident part of a trend? – Risk to the organization Page 7

Principles for Investigation Success Remember: Incidents don’t just happen, they are caused Incidents can be prevented if causes are eliminated Causes can be eliminated if all incidents are investigated properly Unless the causes are eliminated, the same situation will reoccur

After Page 29

Incident Causes Page 7

When an Incident Occurs

First Things First Notify appropriate individuals according to the procedure Grab the investigation kit/contact OH&S or patient safety Approach the scene First on the scene: Check for danger – safety first Provide appropriate assistance in a timely manner Secure the scene Assure the evidence is preserved – don’t throw anything away Page 8

Get the BIG Picture Investigators should ask broad, general questions such as: What was taking place at the time of the incident? Who was involved? Who might have seen what happened? What equipment, machinery, tools, chemicals, etc. were involved? Are there obvious contributing factors such as liquid on the floor, known untrained/inexperienced workers training, broken equipment, damaged materials?

Get the Big Picture for the Incident Scenario In your groups go to page 24 and answer the Big Picture questions

The process for success Remember C.A.R.T C - Collect the Evidence A - Analyze the Evidence R - Report & Recommend T - Take Action Page 8

Collect the Evidence Physical Documentation Witness Page 8 Diagram

Collect the Evidence – Physical Information It May Provide What actually went wrong and why What happened before, during and after the incident Hazards in the work area Effectiveness of engineering controls What caused the injury and how Page 8

Handling Physical Evidence Use safe collection and handling procedures Identify, collect, label, package and store When possible and if applicable don’t remove any evidence until has been examined by the expert (manufacturer, engineer, trainer, etc.) Record the locations where the evidence was found

Take Photos or Video Start with a wide view of the area – Narrow down to specific areas to show detail Keep a log of all photos and locations Use a common object for a size reference when appropriate Check to see if any relevant pictures or videos were taken by others Call your OH&S support team

Sketches Make as soon as possible after the incident Use a scale if appropriate – Measure distances and include on the drawing – Can be for a bird’s eye view Label landmarks, evidence, directions, etc. if it could possibly be relevant See sample forms

Collect Physical Evidence for the Incident Scenario In your groups go to page 24 and answer the Physical Evidence questions

Collect the Evidence – Documentation Standards and technical information – Legislation, industry standards Reports – Inspection, investigation, incident, hazard Records – Training, orientation, maintenance, repair logs Research – Technical, best practice, safety alerts Safety Management Systems documents Page 9

Using Documentary Evidence Use it to help: Determine worker training Determine supervisor training Understand safe work practices and procedures Identify witnesses and questions to ask Check statements given by witnesses Monitor the SMS

Conducting Research Used to learn more about the physical and documentary evidence Benchmarking – What are others doing? – What are the best/industry practices? – Have others had the same experiences? – Have others made changes to their practices? Technical Research – Internet – Journals – Subject matter experts Page 10

Collect Document Evidence for the Incident Scenario In your groups go to page 25 and answer the Document Evidence questions

Return the scene to normal Once the required evidence is collected: Clean and disinfect the area as required Check equipment and materials to assess functionality Ensure that the scene is returned to safe use Ensure that the incident will not be repeated If in doubt about safety of processes or equipment Refer too those who are technically qualified

Collect the Evidence – Witnesses Page 11

Collect Interview Evidence Keep an open mind Be curious

Categories of Witnesses Eyewitnesses Those who came on the scene immediately after the incident Those who saw events leading to the incident Those who have information about the work tasks, processes, safety devices in use, materials, equipment and other conditions involved in the incident Those with expertise

Planning the Interviews Identify who to interview and the information that the interview may provide Use physical and documentary evidence to help prepare questions Find an appropriate interview location Minimize interruptions

Effective Interviews Interview within 24 hours if at all possible – Sooner if the witness won’t be available Set a schedule Put the interviewee at ease – Assure they know the purpose is to collect information NOT to find blame Listen first, then take notes Consider the background and credibility of each witness – all good – all bad

Questioning Techniques Ask questions to: – gain knowledge and details – clarify an observation from the scene Ask open questions (not yes/no) Ask clarifying questions (yes/no) only to narrow down a detail Pause, give the person time to answer, don’t interrupt

Develop Standard Questions Standard script for all interviewees Look for trends What were you doing when the incident occurred? What did you see? What did you hear? Who else was around at the time? What is the standard procedure for the task? What training do workers receive in the standard procedure? Who was supervising the work at the time? Is there anything else you’d like to add?

Interview Order Interview those who were involved, saw it, or were 1st on the scene Next, interview those who know what was happening before the incident Finally, interview others like a trainer, technical expert, other workers Conduct follow-up interviews as required

Collect Interview Evidence for the Incident Scenario In your groups go to page 25 and answer the Interview Evidence questions

Analyze Incident Factors People – Supervision, training, orientation, etc. Material – Substances, tools, equipment, etc. Environment – Workplace conditions, etc. Work process – Work flow, work design, alignment with JSA and procedures System – Policies, procedures plans, JSA, etc. Page 12 Diagram at Back

Analyze Incident Factors for the Incident Scenario In your groups go to page 26 and your handout and answer the Analysis of Incident Factors questions

Analyze Evidence - WHY Start linking together the evidence and incident factors to clarify discrepancies and identify: direct cause indirect causes root causes (system level problems) What seems like a straight-forward event rarely has a SINGLE cause Page 15 Diagram at Back

Identify the Direct Cause Usually happens immediately before the incident The following actions help to describe the Direct Cause – – – – Struck by Fall Caught in, on, between Contact with, exposure to, etc. Often involves an unsafe act or substandard conditions Page 15 Diagram at Back

Analyze the Evidence for the Incident Scenario In your groups go to page 27 and answer the Analyze the Evidence questions

Identify the Indirect Cause(s) These conditions usually set the stage for the incident Examples: – – – – – Lack of training Departures from safe work practices/standard work Not following MSDS/SDS Using inadequate or defective equipment or materials Inadequate PPE Page 15 Diagram at Back

Analyze the Evidence for the Incident Scenario In your groups go to page 27 and answer the Analyze the Evidence questions

Identify the Root Cause(s) Root causes explain why substandard acts and conditions exist Examples: – Lack of knowledge could mean inadequate training and/or orientation systems – Worn, damaged or broken equipment could mean inadequate inspection or preventative maintenance systems – Trained worker not following safe work procedures could mean inadequate supervision systems Page 15 Diagram at Back

SMS Elements 1 Management and Leadership 1.1 Governance 1.2 Senior Management Involvement 1.3 Health & Safety Policy 1.4 Worker Rights 1.5 Responsibilities 1.6 Accountability 1.7 Safety Rules 1.8 Measurement 2 Hazard Identification and Control 2.1 Risk Assessment 2.2 Safe Work Practices/Procedures 2.3 Personal Protective Equipment (PPE) 2.4 Procurement 3 Training and Communications 3.1 Training 3.2 Orientations 3.3 Occupational Health Committee 3.4 Communication 3.5 Document Development, Review and Communication 3.6 Employee Involvement 4 Inspections 4.1 Inspections 5 Reporting and Investigation 5.1 Reporting 5.2 Investigations 6.1 Emergencies Diagram at Back

Analyze the Evidence for the Incident Scenario In your groups go to page 27 and answer the Analyze the Evidence questions

Reporting, Recommendations and Follow-up Page 16 Diagram at Back

Reporting and Recommendation The intent of the report is to: Detail specific recommendations Effect change Improve the health and safety at the workplace

Hazard Control Methods At the source Along the path At the worker Elimination Barriers Training Substitution Absorption Supervision Redesign Dilution Policies & procedures Isolation Hygiene practices Automation Administrative PPE Short term - - Long term Page 16

Actual Harm Rating 1 Minor 2 Moderate 3 Major 4 Severe Frequent Occasional Uncommon Remote Description An incident that has contacted or affected a patient/worker and resulted in no injury or minor injury/haram requiring minimal intervention or first aid. Harm/Injury which requires professional or medical treatment beyond first aid. Harm/injury resulting in physical and/or emotional harm and lessening of bodily function. Temporary loss of function. Long term incapacity/disability. Death or significant harm resulting in irreversible complications including permanent major loss of function. Possibility of repeated occurrence (daily, weekly or monthly) Possibility of occurrence (several times in 1 to 2 years) Possibility of isolated occurrence (2 to 5 years) Not likely to occur (may happen outside of 5 years)

Develop Recommendations Recommend short and long term corrective action: Direct causes – Such as ensuring all hazards are identified at the workplace Indirect causes – Such as ensuring workers are trained in the safe work practices for their job Root causes – Such as reviewing the SMS to insure that processes are in place to identify and control hazards, and to ensure adequate training, orientation and supervision processes are in place Page 17 Diagram at Back

Develop Recommendations for the Incident Scenario In your groups go to page 28 and answer the Analyze the Evidence questions

Reporting and Recommendation The investigation report should include: Description of the incident in detail Factors that led to the incident as determined by the investigation Incident direct, indirect and root causes Risk of inaction Make recommendations for corrective action – Short and long term Ensure a follow-up mechanism

Write the Report for the Incident Scenario In your groups go to page 29 and answer the Write the Report questions

Take Action Employer/Management is responsible for: Acting on the recommendations, and the development of a plan Implementation of the corrective action Supervisors are responsible for: Working with leadership and OHC on implementation and follow up Communication of corrective action to all employees Workers are responsible for Following safe work procedures determined by the corrective action Identifying to their supervisor if the corrective action does not work OHC are responsible for Monitoring the effectiveness of the control Reporting to management Page 18

Take Action Process to implement recommendations: Employer reviews the investigation report Employer reviews the recommendations Employer decides what action will be taken OHC/Rep provides input and monitors the effectiveness of the employers corrective actions * Accountability

Follow-up

Major Reasons Incidents Re-Occur Investigations are not done Direct, indirect and root causes not fully considered Poor communication with employees on cause and corrective actions Corrective actions; not implemented or followed up

Remember Incidents don’t just happen. They are caused. Incidents can be prevented if causes are eliminated Causes can be eliminated if all incidents are investigated properly Unless the causes are eliminated, the same situation will reoccur

Please complete and hand in your evaluation on page 30 of your workbook Thanks for your participation