Accident investigations: Consider root causes, prevention opportunities, and '4Ps'
Objectivity, documentation skills make OHNs natural investigators
Occupational health nurses have to be the salespeople of safety and accident prevention in their workplaces, all while having little actual control over safety and prevention.
"It's a difficult job for occupational health nurses and safety professionals to deal with," says Gerry Burke, MS, BSN, RN, an occupational health consultant and the safety manager for a Pennsylvania printing company.
Occupational health nurses know that investigations of accidents and near-misses can provide important insights into operations and processes, and present opportunities for improvement. Burke suggests that by examining what she terms "the four Ps" — people, parts, positions, and papers — the occupational health nurse stands the best chance of turning an accident or near-miss into a valuable learning experience.
"Administration and managers' goal is productivity, and sometimes safety gets swept by the side — not intentionally, because their heads are in the right places," says Burke. "If you're not productive, you're not going to survive."
Is there such a thing as an 'accident'?
Burke says she doesn't care much for the term accident. "Accidents are so preventable — they are really incidents," she insists. "They are preventable. We have control over them."
The American Association of Occupational Health Nurses (AAOHN), in a recent bulletin to members regarding incident investigations, notes, "In occupational health and safety, 'incident analysis' is replacing 'accident (implying chance, not preventable) investigation' (implying search for the guilty party or one element or person responsible) because of the somewhat negative connotation of the older terminology." (See "Resources," at bottom of article).
Though an accident or incident or near-miss might not be the result of intentional negligence or mismanagement, Burke says, many can be tracked back to management decisions.
"A lot of accidents that do happen go back to management, not ensuring that rules are enforced, or they have not thought out the position that employees are in," she explains. "Safety and health [requirements] are seen as a nag, or as counterproductive, when in reality they can prevent lots of production and maintenance problems in the first place."
An example she gives of an accident occurring because of employee positioning occurred when one employee on a mezzanine above the floor called down to a co-worker to toss a rag up to him. The rag had solvent on it — as was intended — but when the worker on the floor threw the cloth up, solvent dripped back down into his eyes.
The issue that should have been addressed to avoid such an event, Burke says, is the fact that there was no good way to take tools and materials from the floor to the mezzanine level. The only way up or down was via a ladder.
"We had never given employees a good way to carry things up to that level," she continues. "They have to use ladders, and we want them to use two hands, so they can't carry things. That's a management problem — they need a winch or hoist system in that setting."
Other incidents are not the result of safeguards being in place, but of the safeguards not being observed or enforced.
"It's left up to safety — management says 'you train them, and we don't want to be bothered reminding them to adhere to safety,'" she says. "I get very frustrated with that, because a lot of times administrators and managers are not trained to manage other people — a lot of times, supervisors are in their jobs because they have done well at their tasks, not because they are ready to manage other people."
AAOHN's bulletin on incident analysis makes a similar observation: "A superficial incident analysis may conclude 'worker error' caused the incident, and the proposed preventive action is 'reprimand the worker' or 'tell the worker to be more careful.' This approach acts as a barrier to developing preventive occupational health and safety practices. The theory of accident proneness has no empirical foundations. The real key to successful incident analysis is identifying root causes and underlying system failures."
Use '4 Ps' to guide investigation
When Burke approaches an accident or near-miss investigation, she looks at the people, positions, parts, and paperwork that were directly or indirectly associated with the incident:
- People — Interview the people who were involved and those who were close by when the incident happened. Burke says it's important not only to know what they may have experienced, seen, or heard, but also what their relationship is to the team and the others involved.
"There may be a tendency to cover for each other, because they don't want to see someone in trouble for an unsafe act," says Burke. "Sometimes, a supervisor will start an investigation; look at the people aspect of that. They are also responsible for the people and the process, so will they get the answers you need?"
On the other hand, she says, occupational health nurses can come in as impartial investigators, look at the available information and evaluate it, and determine if it makes sense.
- Positions — The location of equipment and people at the time of an accident or near-miss is important to establish, she says. What could the people in the area have seen? How good was the lighting? Were parts or equipment moved after the incident, or at the time of the incident were they in atypical locations?
"Diagram the scene, take photos, or both," recommends Burke. "Recall is difficult over time, so trying to get something at the scene as soon as possible is important. And be careful about taking pictures, because plant managers might not like it."
Photos taken at the scene of an accident or near-accident are excellent educational tools, she adds. "Show what's wrong — or what's right —- with this picture."
- Parts — If the incident involves equipment or tools, learn about the parts. Ask the people who work with the equipment if it was performing correctly, if there were problems. If a piece of equipment is broken, lab analysis might be needed to detect hairline cracks and other details.
"Ask questions about the parts being used," suggests Burke. "If substitute parts are being used to save money or because the original parts are not available, they might not have been appropriate or strong enough."
- Paperwork —- Documentation can tell the occupational health nurse whether the right person was doing the appropriate work at the time or location of the incident.
"Was someone out sick and someone filling in who wasn't as experienced?" Burke suggests asking. "Were they following the manuals? Did they even have manuals?"
Paperwork can indicate whether employees were aware of hazards involved in the process or with the equipment; if standard operating procedures were followed as a rule; and whether the employees involved had ever had previous incidents indicating a pattern of unsafe practice.
"You don't want to blame employees for a management problem, but if there's a consistent problem with an employee, you need to deal with it," she explains. "You're not looking to blame, but toward getting good information to prevent recurrences."
Get good information, then put it to work
The most useful information to be gleaned from an incident or near-miss is probably going to come from the people who work in the area or with the equipment or processes involved, points out Burke. Maintenance workers can be very helpful, due to their knowledge of repairs or problems.
Documentation of the incident will likely be assigned to the nurse, "because everyone knows that nurses document well," Burke comments. "Hopefully, you have enough on paper that you feel good about it."
At Burke's workplace, accident findings (minus the names of the people involved) are dated and posted alongside a report detailing prevention strategies and a request that workers try the prevention strategies and report back to the safety committee about their effectiveness.
The nurse might be called on to participate in "acceptable risk" discussions, when decisions are made balancing cost and risk.
"Even with the space shuttle, there are accepted risks," says Burke. "They can't engineer out everything — it would cost too much. So you say 'we can accept this risk, but not that one.'"
The acceptable risk discussion is most commonly seen when new equipment is being purchased, and safety add-ons are debated. Each safety feature comes at a price, and at some point, Burke says, there is likely to be a decision on whether the likelihood of an event is outweighed by the cost.
If the occupational health nurse can demonstrate that he or she is interested in understanding what the factors are that contribute to safety issues and is willing to help out, rather than simply offering negative feedback — even so far as offering to help locate parts — he or she is then seen as a team player and not just a maker and enforcer of rules.
"What's hard to change is the cultural issue, when time goes by and they lapse back into the behaviors [that contributed to the accident]," she explains. "That's when nurses can be a real pain in the neck. But if we've had another accident or near miss, then we're repeating the same problem, and people don't like to hear that. "But that's our job, and we need to keep after it."
Source and Resource
Gerry Burke, MS, BSN, RN, safety manager; occupational safety and health consultant, Birdsboro, PA. Email: [email protected].
American Association of Occupational Health Nurses (AAOHN), Atlanta, GA. Phone: (770) 455-7757. "Incident analysis" advisory available online at www.aaohn.org/practice/advisories/upload/advisory_incident.PDF.
Occupational health nurses have to be the salespeople of safety and accident prevention in their workplaces, all while having little actual control over safety and prevention.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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