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.

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

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.