Root-cause analysis not a blame game

incident-reporting-program

The summer edition of Vitality Atlas, WorkCare’s quarterly newsletter, features two articles with juxtaposing ideas about the root causes of workplace accidents and injuries.

In the cover story on OSHA’s new severe injury reporting rule, the agency places the weight of responsibility for work-related injuries on employers.

In a speech in which he explains the reasoning behind the rule, OSHA director Dr. David Michaels says “employers blame too many injuries on ‘careless workers’ when we know the real cause of most incidents in which a worker is hurt is the presence of an unabated hazard. Too often we see employers blaming workers for being injured when that very employer has failed to provide protective equipment or guards or failed to train their workers in safe work practices.”

According to Michaels, investigating a worksite incident – whether it is a fatality, injury, illness or close call – provides employers and workers the opportunity to identify hazards, uncover safety and health program shortcomings and implement corrective actions. “In conducting an incident investigation, the team (managers, supervisors and workers) must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident,” he said.

Scroll inside the newsletter and you’ll find an article about how an employee’s experience and emotions influence decision-making in the moment. Joseph L. White, a solutions architect and senior safety consultant with DuPont Sustainable Solutions, explains why workers sometimes take actions that may seem careless or ill-conceived to an observer.

White is intrigued by the concept of personal biases, patterns and feelings as defining factors for workplace safety, security and operational excellence. Applying psychological principles, White says:

  • people with good intentions are wired to routinely take chances
  • decision-making is predominantly a subconscious process
  • most decisions have an emotional basis

According to White, employers who understand heuristics – learning through experience or trial and error – and the mental short cuts people use to interpret and respond to information in real time have an advantage over those who do not.

He believes vertical and horizontal leadership, peer-to-peer engagement and an association with “something that can be achieved, not something to be avoided” is needed to raise the safety performance bar. While recognizing that data is useful when monitoring performance, he recommends infusing health and safety training programs with images, videos and personal stories because people retain messages that “reach the heart and not just the head.”

No wonder an investigation will often uncover multiple contributing factors when there is a near-miss or a worker is injured on the job.

When conducting a root-cause analysis, it’s important to remember that blame is not the name of the game. When properly done, a root-cause analysis will likely reveal a host of physical, human, organizational or systemic contributors. In turn, a multi-disciplinary response is required.

Karen O’Hara

Posted by, Karen O’Hara

Comments

  1. Are there any rules, laws, or codes that protect staff from being on the receiving end of the “blame game”, and thus intimidated by the reporting process. 38 USC 1575 ensures information gathered for quality assurance programs must be deidentified (patient and staff identify removed). Are there any similar protections for non veteran hospital staff being identified in quality assurance programs?

    1. From Dr. Jeffrey Jacobs, WorkCare Associate Medical Director: Assigning blame is never helpful when dealing with an injured worker, but unfortunately, that sometimes can be the case. To defuse the potential for adversarial situations, I recommend stressing a non- or at least less-judgmental approach on the part of all parties who are engaged with injured employees. I’ve found that listening to an injured worker’s explanation of events goes a long way toward establishing a trusting relationship and improving health outcomes, which is a win-win in everyone’s book. As far as any rules or regulations protecting staff, I would recommend consulting with an attorney who has expertise with workers’ compensation rules/regulations in your jurisdiction.

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