No more excuses: Every accident is preventable
Accident investigation seeks out the ‘why?’
It’s never “just an accident” when someone gets hurt.
Even an unusual accident can shed light on weaknesses in your processes and procedures, says Linda Haney, RN, MPH, COHN-S, CSP, clinical director of Diligent Services, a consulting division of Arjo Inc., the health care ergonomics firm based in Roselle, IL. If you ask the right questions after an accident or a near miss, you may be able to prevent future incidents, she says.
“If you say, ‘If it’s going to happen again and you know now what you didn’t know then, what would you change?’ there’s always something you can change,” Haney says.
By conducting regular accident investigations — sometimes called after-action reviews — hospitals can lower their injury rates and improve the overall safety climate, safety experts say.
The “accidents are preventable” attitude is pervasive in other settings. For example, Dupont chemical company sets an expectation of zero accidents, Haney notes. The U.S. military also has integrated after-action reviews into its culture.
Investigations can be formal, such as those conducted by safety committees. Or they can be informal, such as discussions before shift changes about problems or potential problems. But they should never be punitive, safety experts agree.
With the right atmosphere, employees will feel comfortable brainstorming about what led to an accident or what steps could have prevented it. In that context, they may mention safety concerns that haven’t yet led to injury, notes Mary Matz, MSPH, a Tampa, FL-based national patient care ergonomics specialist for the Veterans Health Administration (VHA).
“You can just learn so much from the near misses and close calls to prevent injury,” she says.
Repeatedly asking ‘Why?’
Having the right mindset is the first step toward effective accident investigation. Often the employee takes the blame, and the injury report simply notes “carelessness,” “distracted,” or “didn’t follow procedure.” The common solution: Retraining.
But Haney urges employers to ask the “5Ys,” which triggers a repeated questioning of “Why?” Why were you distracted? Why didn’t you follow procedure? Why did you feel hurried?
Ultimately, the “why?” questions assume that there should be safeguards or backups built into the process to prevent accidents. Not just the employees are responsible, Haney says. Management also plays a role. “You have to start with the mindset that accidents are a controllable management function,” she says.
Here’s an example: A resident in a long-term care facility fell to the floor, and two nursing aides rushed to help him. They lifted the 6-foot-2-inch resident manually, and both suffered serious injuries. The man had previously objected to the use of a mechanical lift, and administrators said that was his prerogative.
“What could be done to prevent that?” Haney asked. “Nothing,” the administrators answered.
“If I told you this afternoon that exact same thing was going to happen, can you think of anything that could be done to protect those employees?” she asked.
With some brainstorming, the administrators agreed that the patient could be acclimated gradually to the lift. A lift was placed in the room for a while, without being used. Then nursing aides slipped the sling under him but didn’t use it. They also talked to the resident about the injury of the nursing aides, the lift equipment, and why it was important for his safety as well as theirs.
“Sometimes it takes a lot of creativity, but you can prevent those injuries,” Haney says.
Managers bear responsibility
Accident investigation actually is not an employee health or safety committee function. It should be carried out by the manager or senior manager with input from employees, safety experts say.
Managers need to take responsibility for accidents that occur in their departments, explains Haney. “Do you have responsibility for what goes on with your patients on your unit? Do you have responsibility for staffing it? Then you also have responsibility for the people who are there,” she says.
In the VHA, back injury resource nurses (BIRNs) on each unit become safety coaches who engage in other types of accident investigation, as well, Matz adds. After-Action Reviews occur on each shift, in each unit.
The units decide how to structure them, but often they occur at a shift report when employees talk about the upcoming shift.
Other units have regularly scheduled meetings. A short synopsis provides lessons learned that can be shared with other shifts and units, and BIRNs also spread the word.
An example: Nurses on a unit of a VHA hospital weren’t using the lateral-transfer devices. Someone raised the issue at a unit After-Action Review, and nurses complained that the devices were just too narrow. The patients didn’t fit.
The unit brought up the complaint with a manufacturer representative, and the manufacturer ended up redesigning a broader device. “You can just learn so much from the near misses and close calls to prevent injury,” Matz says.
Conducting an accident investigation or After Action Review isn’t difficult, but it is useful for a facilitator to have training in accident investigation. The American Society of Safety Engineers (www.asse.org) and the National Safety Council (www.nsc.org) offer on-site seminars in incident investigation.
Information on how to conduct an After-Action Review also is available on the safe patient handling web site of the VHA Patient Safety Center in Tampa at www.patientsafetycenter.com/AAR_rev081103.pdf.
It helps to have a clear form that guides the team through the accident investigation. (See a sample form for patient handling injuries.) But a form can’t take the place of some nonjudgmental, probing questions.
If an employee tells Haney that the accident happened because she was in a hurry, Haney follows up: “Help me understand why. What was different about today?” Employees may simply say they are understaffed, and the hospital may be unable to add staff because of budget constraints. But that isn’t the end of the prevention effort, Haney says.
“I say, realistically, do you really think you’re going to get more people? If not, we’ve got a choice to make. Do we continue to use that as an excuse for injury, or can we figure out a better way [to function] with the staff we have so we’re still safe? People always have choices. They often don’t think they do, but they do,” she says.
Ultimately, a system of accident investigation builds teamwork, says Matz. And that in itself is a step toward a safer workplace.
“You have to have at least the beginnings of some kind of an effective safety culture to carry this out,” she says. “There has to be trust among team members.”
Its never just an accident when someone gets hurt. Even an unusual accident can shed light on weaknesses in your processes and procedures, says Linda Haney, RN, MPH, COHN-S, CSP, clinical director of Diligent Services, a consulting division of Arjo Inc., the health care ergonomics firm based in Roselle, IL. If you ask the right questions after an accident or a near miss, you may be able to prevent future incidents, she says.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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