Accident investigations improve safety

Thorough accident investigations are invaluable in creating safer workplaces

What a perfect world it would be if accidents never happened. But sadly, accidents do happen, and even more sadly, we often accept them as a part of doing business.

Accidents do occur in long-term care. We know that. We also know that the Bureau of Labor Statistics recognizes long-term care as one of the highest-rated industries for occupational injuries. And be that as it may, we often seem all too willing to view these accidents as unavoidable, even before we know anything about them. And that is where our safety program breakdowns start to occur.

Over the years, I have asked a lot of managerial employees why they investigate accidents. The common responses include:

* Exonerate individuals (or management)

* Satisfy insurance requirements

* Defend a position for legal arguments

* Determine blame/responsibility

Whenever an occupational accident occurs, a basic investigation is Through the investigation, we learn about causation, and we can put improvements in place to reduce the chances of recurrence. I'm not talking about occupational accidents that result in injury; I am talking about all occupational accidents. Even if any injury didn't occur this time, a catastrophic injury from the same event may occur next time. Don't wait for that to happen.

First and foremost, we must remind ourselves why we investigate accidents. Too often, I see my clients investigating accidents with what seems like a hidden agenda to place blame. It's almost as if the mind-set is. "something happened, and someone has to be blamed."

Forget it. That doesn't work.

Find the cause

Accident investigations are done to identify contributing factors that led up to the event. The more we know about contributory causes, the better job we can do with our safety management program to lessen the chances of recurrence. Looking for that person to blame puts people on the defensive, resulting in a compromised investigation. When you create a culture that proves that your goal is to learn from every event to prevent a recurrence, you have already won half the battle. Staff will be forthcoming, give honest answers and work with you to achieve the desired results.

First, what is an accident? In simple terms, I define an accident as any unplanned and unwelcome event that interrupts normal activity. You will notice that I don't talk about injuries or damages at all. That is an outcome of an accident, not an accident itself.

Imagine driving home from work, and you are stopped at a traffic light, when the vehicle behind you fails to stop and runs into you. Was it unplanned? Sure. Was it unwelcome? Did it interrupt your normal activity (driving home)? It sure did. Can it be called an accident? You bet.

Accidents and outcomes

Every accident has outcomes. We typically think of outcomes as negatives, but I believe we can make them something positive as well. Negative outcomes include death and injury disease, damage to equipment/property, litigation costs and lost productivity.

On the other hand, accidents can have positive outcomes such as becoming a learning opportunity; generating improvements to the safety programs; demonstrating the organization's commitment to safety and becoming a training/teaching opportunity, which improves morale.

It is often debated who is best suited to conduct the accident investigation. Many times, organizational leaders will turn to the safety officer, suggesting it is his or her job. Others will suggest that the administrator should assign someone to conduct the investigation, based on circumstances. As a safety professional, I am a believer that the person most qualified to conduct the initial accident investigation is the injured employee's supervisor.

Typically, the supervisor will know the responsibilities of the position better than anyone else, and will know the right questions to ask. And knowing the answers to the question in advance makes it much easier to conduct a more thorough investigation.

Every accident that occurs can be classified into one of three categories:

1. Unsafe acts (human element)

2. Unsafe conditions (environmental/design/ structural)

3. Acts of God

Once the event is categorized, it becomes easier to move the investigation forward. Look through old accident reports and see what was written as "factors" leading up to the accident. Often, I see what we call "attribution errors," which are usually the result of trying to rush through an investigation, looking for the simplest and most obvious answers. Attribution errors typically look for someone to blame, and use phrases such as:

* The employee is lazy.

* The employee lacks common sense

* The employee was inattentive.

* The employee was careless

* The employee is accident-prone.

* The employee should have known.

* The employee has a poor attitude.

Even if one or more of these statements are true, a thorough accident investigation will help to uncover reasons why the statement was made, and why it was true.

It is important that we think about the way we approach accident investigations and the strategies we use.

An accident investigation is not an exercise in placing blame or finding someone at fault. It is a fact-finding mission. As a supervisor, our person and approaches accident investigation will set the stage for the flow of the investigation itself as well as the outcome.

I believe that the accident investigation begins with the completion of some version of an employee injury form. My popularity may crash, but I truly believe that the employee injury report should be completed by the supervisor of the injured staff member and not by the injured employee.

When I do a safety audit in a long-term care facility and its injury reports, it is common to find the entire report filled out by the injured employee. And, as a result, it is equally common to find reports that paint a picture of the employee as the poor innocent victim and the facility as the big bad wolf that cares nothing about employee safety. Now imagine those reports are to be reviewed by an attorney or by a judge in workers compensation hearing.

Again, here goes my popularity down the drain: The supervisor who hands an employee injury report to the injured employee and says "fill this out" is either an untrained supervisor or a lazy supervisor. If you want to hand the form to the employee to complete the personal information section (name, date of hire, department assigned to position, etc.), that is fine, but beyond that, the report must be seen as a management tool and must be completed by properly trained supervisors who ask the right questions and properly complete the documentation.

Gather information

When completing an accident investigation, it is important that the supervisor first review any applicable policies and procedures, job descriptions, job safety analysis and any other available information that gives the supervisor a clear understanding of the employee's responsibilities and the specifics of the task being performed when the injury occurred. If equipment is involved, preventive maintenance records as well as any records of repair should be reviewed in advance.

Time is of the essence. Conduct the accident investigation as soon as possible after the actual event, when it is fresh on everybody's mind, when critical details will be remembered and when stories have not had a chance to be fabricated and/or embellished. The supervisor should gather as much information as possible from the injured employee, coworkers, witnesses and anyone else with relevant information or knowledge of the actual event or circumstances leading up to or contributing to the event.

Conduct an effective interview

The supervisor needs to interview the involved employee soon after the incident. This is a critical part of the investigation, and I want to emphasize that this is a fact-finding mission and not a blame-placing mission. It is important to gather true and complete answers if this information will be used to improve the safety management program.

Part of a successful investigation is the ability to ask questions the right way. Always ask open-ended questions; that is, questions that elicit an explanation from the injured employee rather than simple yes or no answers. For example, which question would provide better information for your investigation?

1. Were you wearing protective equipment?

2. Explain what protective equipment you are wearing and how you're wearing it.

As you can see, the first question is going to result in a simple yes or no answer, followed by the dreaded "pregnant pause" The second question, while implying an assumption that personal protective equipment was being worn, actually puts responsibility back on the employee to not only confirm wearing the protective equipment, but to explain how it was being worn. This not only confirms for the supervisor that the equipment was being used, but also gives a clear indication if the employee understands the proper way to wear and use the personal protective equipment.

It is also important to separate fact from opinion. While the employee's opinion may be important, the injury report is not the place to share opinions. The supervisor should always make sure that the information in the injury report is a factual representation of the incident, free from biased opinions.

Find the root cause

Determining the root cause of the incident will often allow us to identify ways of preventing recurrence in a much more expedient manner. Often, when conducting an accident investigation, we become so focused on cause that we forget to look beyond the obvious. For example, some of the more basic causes that we commonly see identified include unguarded machines, broken tools, ignored hazards, rushing through heavy work volume, horseplay.

Unfortunately, if we had dug a little deeper, the real underlying (root) causes may have been identified, such as:

* inadequate training

* poor orientation process

* little or no employee accountability

* poor preventive maintenance plan

* no enforcement or disciplinary action plan

Conducting a thorough and comprehensive accident investigation is neither convenient nor quick. It takes time, focused energy and a willingness to keep digging until all of the questions are answered and all of the answers are clear.

In the end, several gains will be recognized as a result of a complete and thorough investigation such as an increase in productivity because of fewer accidents and interruptions and improved operational and safety procedures. Other gains include a heightened awareness of the organizational commitment to a safe workplace, along with improved financial performance

Stay safe and stay in touch!

An accident inuestigation is not an exercise in placing blame or finding someone at fault. It is a fact-finding mission.

Time is of the essence. Conduct the accident investigation as soon as possible after the actual event, when it is fresh on everybody's mind, when critical details will be remembered and when stories have not had a chance to be fabricated and/or embellished.

BY STEVE WILDER, CHSP, STS

Steve Wilder, CHSP, STS, is president and CEO of Sorensen, Wilder & Associates, a healthcare safety and security consulting group based in Bourbonnais, Ill. Contact him at (800) 568-2931 or at swilder@ swa4safety.com.