Incident
Investigation -- Tips, Techniques & Trivia
I'm on the
road delivering training for the remainder of this month. An associate
is available to assist you with any investigations should the
need arise. Contact info is on my voice mail.
Attention
First Time Readers: Welcome to the 100 or so new readers
that signed on in May. If you are looking for more investigation
resources see my web site for articles, links and copies of past
newsletters.
Jeff
Canadian
Root Cause Analysis
Summer Reading
This is not your light summer reading! However,
if you are interested in learning a little more about improving
your root cause analysis processes then this will be time well
spent. On top of that, it's free.
A 2004 Canadian research project examined medical
adverse events. In medical terms adverse events are unintended
injuries or complications resulting in death, disability or prolonged
hospital stays arising from health care management. (Adverse events
would be the equivalent of a lost-time injury in the safety world.)
The statistics coming out of this study of adverse
events are surprising:
-
a 7.5% adverse event frequency rate
-
36.9% of adverse events were felt to be preventable
-
5.2% resulted in permanent disability
-
1.6% were associated to patients who subsequently
died
The Canadian Patient Safety Institute has published
this 50 page book and made it available on the web for downloading.
While the focus is our medical system, any reader should be able
to identify at least 3 or 4 good ideas readily transferred to
any type of work environment.
Root
Cause Analysis Workbook
Notifying
Next of Kin
Whenever a conversation touches on a workplace fatality
and people know I'm a former police officer, they invariably say
the one thing they could never do is knock on someone's door and
tell them of a death in the family. In the case of a workplace fatality
the job of notification may be done by the police, or more likely
a family friend or co-worker, which unfortunately, might be you.
Here's what police officers are instructed to do. Let's hope you
never have to use it.
- Introduce yourself at the door and ask to
come in.
- Say, "I have some very bad news for you,"
to prepare them for your news.
- Tell them of the death directly and simply.
- Don't hug them but let them hug you if they
need to. Don't shy away.
- Let them talk while you listen. Don't judge.
- Stay with them until family, a friend or neighbour
is there.
- You may refer them to a professional such
as clergy, counselor or funeral director.
- Leave your business card or contact information.
Source: Canadian Association of Chiefs of Police.
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