Document 191968

David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax HOW to INCREASE
NEAR MISS REPORTING
DAVID PATZER
DKF Solutions Group, LLC
[email protected]
707.373.9709
Have you ever been
involved in an
Accident
Investigation –
where the
contributing factors
of the Accident
happened before but
weren’t reported?
______________________________
Do you find that
your People are
reluctant to report
Near Misses?
1 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Increase Near Miss Reporting
  In order to answer this question, we have to
understand four things:
 
What is a Near Miss?
 
Why Do We Need to Report Near Misses?
 
How Do Accidents and Near Misses Happen?
 
What Are the Barriers to Reporting Near Misses?
If You were asked
to define what a
Near Miss is –
What would You
Say?
Does everyone in
your organization
have the same
definition?
Is that a
problem?
2 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Accidents, Incidents and Near Misses:
What are They?
  The National Safety Council offers the following
definitions, which are recognized by OSHA:
  ACCIDENT
– An accident is an undesired event that results in
personal injury or property damage.
  INCIDENT
- An incident is an unplanned, undesired event that
adversely affects completion of a task.
  NEAR
MISS - Near misses describe incidents where no property
was damaged and no personal injury sustained, but where, given
a slight shift in time or position, damage and/or injury easily could
have occurred.
If nothing “bad” happened, why report Near Misses?
CSRMA Examples of Near Misses
In the work of replacing the bucket securing pin, a mechanic hit the pinhead
with a sledgehammer forcibly. The pin was driven out of the hole in a high
speed and came near to hitting a fellow mechanic on the opposite side.
3 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax From OSHA FATAL FACTS
BRIEF DESCRIPTION OF ACCIDENT
•  A carpenter apprentice was killed when
he was struck in the head by a nail that
was fired from a power actuated tool.
•  The tool operator, while attempting to
anchor a plywood form in preparation for
pouring a concrete wall, fired the gun
causing the nail to pass through the
hollow wall.
•  The nail travelled some twenty-seven feet
before striking the victim.
•  The tool operator had never received
training in the proper use of the tool, and
none of the employees in the area were
wearing personal protective equipment.
A NEAR MISS – is often only an Inch or two away from a Tragedy.
How to Increase Near Miss Reporting
  In order to answer this question, we have to
understand four things:
 
What is a Near Miss?
 
Why Do We Need to Report Near Misses?
 
How Do Accidents and Near Misses Happen?
 
What Are the Barriers to Reporting Near Misses?
4 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax We MUST
find Ways
to Hear and
Learn from
our Near
Misses
Why Report Near Misses
5 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Benefits of Reporting Near Misses
  As a Supervisor/Manager–
 
 
It is hard to argue with the fact that a
Near Miss Safety Incident – is a “Do Over”
without a Cost or Penalty or Injury.
It is also hard to argue that Near Misses
must not only be attended to and
corrected timely – but that they must be
Used as a Learning Experience.
Benefits of Reporting Near Misses
Reporting of a
Near Miss and
the subsequent
Investigation of –
will more than
likely reveal –
acts, conditions, etc.
that will need
to be corrected.
6 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Benefits of Reporting Near Misses
  EXISTING CONDITIONS – Do not be surprised when
investigating Near Misses – to find Unsafe Conditions that
have been present for some time.
  NO STANDARD WORK PRACTICE – Near Miss Incidents
are often caused by having no such standard practice or
procedure in place – which results in having various and
most likely unsafe ways to accomplish a task or
responsibility.
  LACK OF TRAINING – Another condition that leads to
Safety Incidents – is the lack of Training of the Workers
involved – i.e., How to Safely use a Come-Along.
Benefits of Reporting Near Misses
  USING IMPROPER or UNSAFE TOOLS – Can a Near
Miss Incident ever be caused by Management?
 
How about when a Tool is given to an Employee that is
either improper or unsafe to use for the Job that that
they are asked to perform.
  CUTTING CORNERS – Common place in the Work
Place – will be Employees that “Cut Corners” – i.e., not
following the steps that need to be performed in order.
 
Such may be due to Complacency and the belief that
they will not get hurt – or it may include simply trying
to speed up their work process.
7 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Benefits of Reporting Near Misses
  LACK of SAFETY AWARENESS – A leading cause
within my Organization – is the lack of Safety Awareness
by our People involved in Near Misses and Accidents.
 
Such has included – not seeing Co-Workers in their
immediate Work Area – to placing their Body Parts
between Pinch Points – to not checking their work area
prior to setting up or beginning their work.
  OUTDATED PROCEDURES – Organizations must
ensure that when their Processes change – that they
update their Procedures to reflect such changes.
Summary: Near Misses ID Weakness
These Activities/Metrics Allow You To Change Course and Make Too Late
Adjustments BEFORE Something Bad Happens
Leading
Indicators
Attitudes
(set up conditions,
behavior)
- Perception
surveys
Program
Elements
- Training
- Accountability
- Communications
- Planning &
Evaluation
- Roles &
Procedures
- Feet cleaned/tv’d
Physical
conditions
-Inspections
-Audits
-Risk
assessments
-Prevention &
control
Behavior
(action)
-Observations
-Near Miss
Reporting
-Feedback
loops
Lagging
Indicators
Measures
Results
- Accidents
- Incidents
These are BARRIERS to Accidents/Near Misses
Without Measurement, There Cannot Be Management
8 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How Do We Prevent Accidents/Losses?
HINT
How Do Accidents/Incidents/Near Misses Happen?
•  System Defenses
–  Established systems can anticipate how things can go
wrong
–  Foreseeable problems allow the development of
defenses
•  No single defensive layer is sufficient
SYSTEM
SYSTEM
9 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How Do Accidents/Incidents/Near Misses Happen?
•  Hard vs Soft Defenses
–  Hard Defenses
•  Engineered safety features
•  Physical barriers
•  Sensing devices
•  Warnings and alarms
SYSTEM
–  Soft Defenses
•  Rules
•  Regulations
•  Procedures
•  Supervision
•  Sign-off procedures
•  Permit to Work Systems
For something to go wrong,
multiple defenses would have to fail
How Do Accidents/Incidents/Near Misses Happen?
•  What Defenses Are Available to:
–  Reduce the likelihood of an error
–  Reduce the impact of an error
SYSTEM
Automatic Transmissions:
What defense is designed to prevent the car from moving
when removing it from park?
10 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How Accidents Happen
300
How to Increase Near Miss Reporting
  In order to answer this question, we have to
understand four things:
 
What is a Near Miss?
 
Why Do We Need to Report Near Misses?
 
How Do Accidents and Near Misses Happen?
 
What Are the Barriers to Reporting Near Misses?
11 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How Do Accidents, Incidents and Near
Misses Occur?
  Active Failure + Latent Condition = Accident/
Incident/Near Miss
  Active failures
The unsafe acts committed by people who are in direct contact
with the system (slips, lapses, mistakes, and procedural
violations).
  Active failures have a direct effect on the integrity of the system’s
defenses.
 
  Latent conditions
  Fundamental vulnerabilities in one or more layers of the system
  Latent conditions may lie dormant within the system for many
years before they combine with active failures and local triggers
to create an accident opportunity.
Factors Contributing to Accident/Near Miss Causation
conflicting objectives
Management/
Governance
inadequate control of business processes
loose culture
unclear priorities
condone non-compliance
unclear expectations
uncontrolled change management
lack of consequent management
focus on commercial targets
scorecard driven
focus on cost reduction
not open for ‘bad’ news
focus on slips, trips & falls (TRCF)
lack of resources
inadequate standards & procedures
Organization &
systems
inadequate hazard control
inadequate design
human error
no intervention
workload
maintenance back-log
Inadequate monitoring & corrective action
unclear roles & responsibilities
Immediate
causes at sharp
end
time pressure
poor audits and reviews
lack of competence
Pushing operating window
production pressure
inadequate ER system
lack of supervision
poor communication and hand-over
equipment failure non-compliance
acceptance of high risks
lack of hazard awareness
Accident/Incident/
Near Miss
12 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Latent
Conditions
Why Do Things Go Wrong? (Gordon Graham)
Screening &
Consequences
Difficult to Control
E
I
N
T
INTENTIONAL MISCONDUCT
X
T
E
E
R
R
N
A
NEGLIGENT CONDUCT
A
L
L
Errors
N
i.e. vehicle accidents
Recognizing Risks
13 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Human Error
•  Human error is the most common accident cause:
–  "The Origin of Accidents" (1928), Herbert Heinrich examined 75,000
industrial accidents and attributed 88% to "unsafe human acts.
–  "Former National Transportation Board Chair Jim Hill has testified before
a congressional committee that human error causes 70% of accidents in
all walks of life.
–  A Boeing study of major worldwide airline crashes found that 71.7%
were due to human error.
–  Reason (Human Error, 1992), studied 180 nuclear power plants in 1983
and 1984 and concluded that human error was 52% of the root causes.
–  Rasmussen et. al. (New Technologies and Error, 1987) found that 88%
of all occupational accidents are caused primarily by individual workers.
–  Wood et al. (CSERIAC, 1994) concluded that over 70% of operating
room anesthetic incidents involve human error.
–  According to the most complete surveys, over 90% of all highway
accidents are caused fully or in part by human error. And of these, 90%
are caused by perceptual error and 10% by response error. In short,
perception is a factor in over 80% of all highway accidents.
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
ERRORS
Santa Monica Farmers Market
Apollo 13 oxygen tank blow out
Were these
Flixborough cyclohexane explosion
errors committed
Three Mile Island Nuclear Disaster by bad people or
bad
DC10 crash Chicago O’Hare
organizations?
Bhopal India Disaster
Japan Airlines crash
Piper Alpha oil/gas platform explosion
Clapham Railroad Disaster
Phillips 66 Houston Chemical Plant Explosion
Airline cockpit windshield blowout
In flight airline break up
Oxygen generator fire in DC9 in Florida
14 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax QUIZ
•  Which is easier to change?
–  Conditions, or systems, under which
people work
•  OR
–  Human nature
15 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax ERRORS
•  Human Performance Levels
–  3 levels of human performance
Level
Features
Skill Based (SB)
Automatic control of routine tasks
with occasional checks
Rule Based (RB)
Pattern matching prepared rules or
solutions to trained-for problems
Knowledge Based (KB) Conscious, slow, effortful attempts
to solve new problems on the go
RULE-BASED ERRORS
•  Example:
–  1988 Clapham Junction RR Collision
•  Northbound commuter train ran into the back of a stationary train
after passing a green “all-clear” signal on the tracks
–  35 ppl died, 500 injured
•  A maintenance worker had re-wired the signal the day before
–  Didn’t cut off or tie back the old wires, just bent them back out
of the way (bad work habit)
–  Re-used old insulating tape (bad work habit)
–  The tape came off and the wires came into contact causing a
wrong signal to be issued
–  The employee:
»  12 years on the job
»  Described as hardworking and motivated
»  Never received any formal training - learned by watching
others and trying to “figure things” out on his own
»  Result = Bad work habits were never corrected
Lack of Established RULES =
People Make Up Their Own Rules…right or wrong….example Caltrans
16 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax ERRORS
•  Human Performance Levels
–  3 levels of human performance
Level
Features
Skill Based (SB)
Automatic control of routine tasks
with occasional checks
Rule Based (RB)
Pattern matching prepared rules or
solutions to trained-for problems
Knowledge Based (KB) Conscious, slow, effortful attempts
to solve new problems on the go
What about DELIBERATE DEVIATIONS from rules, SOPs,
policy, etc?
VIOLATION ERRORS
•  Characteristics of a violation:
–  Intentional non-compliance with rules
–  Demographics - men violate more than women and young
violate more than old
•  Types of Violations
–  Routine: Avoid unnecessary effort, get job done more
quickly, or circumvent a procedure with seemingly
unnecessary steps
–  Thrill seeking: Macho, bored or just for kicks
–  Situational: Impossible to get the job done if you follow
the established sop - here the problem is with the sop and
sop writer
•  Airlines
–  European airline study: 34% of maintenance tasks were
not in compliance with established sops
–  Australian airline study: 17%
17 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax VIOLATION ERRORS
•  Factors Promoting Violations: Personal Beliefs
–  Remember: Violations are deliberate deviations from
SOPs and safe practice
–  Driving Research:
•  Illusion of control: I can control the outcome
•  Illusion of invulnerability: Underestimate the odds of a bad
outcome
•  Illusion of superiority: I’m more skilled than “they” are
•  There’s nothing wrong with it: Don’t see it as wrong or
dangerous
•  Everyone does it: Violators tend to overestimate the
proportion of others that violate
Managing Risk – The Three Behaviors
•  Human error: unintentional and unpredictable
behavior that causes or could have caused an
undesirable outcome.
•  Most human errors arise from weaknesses in the
system, they must be managed through process,
system, or environmental changes.
•  Discipline is not productive, because the worker
did not intend the action or the risk or harm that
resulted.
•  The only just option is to console the worker and
shore up the systems to prevent further errors.
Disciplining human error angers people and breeds distrust
18 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Managing Risk – The Three Behaviors
•  At-risk behavior: Everyone knows that “to err is human,” but
we tend to forget that “to drift is human,” too.
•  Behavioral research: we are programmed to drift into unsafe
habits, to lose perception of the risk attached to everyday
behaviors, or mistakenly believe the risk to be justified.
•  Over time, as perceptions of risk fade and the tendency is to
take shortcuts and drift away from behaviors we know are
safer.
Managing Risk – The Three Behaviors
•  At-risk behavior, ctd.:
•  The reasons workers drift into unsafe behaviors are often
rooted in the system.
–  Safe behavioral choices may invoke criticism, and
–  At-risk behaviors may invoke rewards.
•  For example:
–  Time to complete a given set of tasks
•  Therein lies the problem. The rewards of at-risk behaviors
can become so common that perception of their risk fades or is
believed to be justified.
•  The incentives for unsafe behaviors should be uncovered and
removed, and stronger incentives for safe behaviors be created.
19 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Managing Risk – The Three Behaviors
•  Reckless behavior:
–  Always perceive the risk he or she is taking
–  Understand that the risk is substantial
–  Behave intentionally, but are unable to justify the risk (i.e.,
do not mistakenly believe the risk is justified)
–  Know that others are not engaging in the same behavior
(i.e., it is not the norm), and
–  Make a conscious choice to disregard risk
•  The difference between at-risk behavior and reckless
behavior:
–  70mph vs 90mph
Managing Risk – The Three Behaviors
•  Three types of behavior can be involved in
error:
–  Human error
–  At-risk behavior
–  Reckless behavior
•  Each type of behavior has a different cause,
so a different response is required.
More on this later…
20 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Increase Near Miss Reporting
  In order to answer this question, we have to
understand four things:
 
What is a Near Miss?
 
Why Do We Need to Report Near Misses?
 
How Do Accidents and Near Misses Happen?
 
What Are the Barriers to Reporting Near Misses?
What % of
Near Misses
do you think
are actually
reported at
your
agency?
21 David Patzer, DKF Solu3ons Group, LLC 6/12/12 Reasons Why Our People
are Reluctant to Report
[email protected] 707/373.9709 cell or 707.647.7200 fax NEAR MISSES
  Employee doesn’t recognize the event (incident) as a near miss
that needs to be reported. "I didn't get hurt – so nothing actually
happened.”
  There
is No System for Near Miss Reporting.
  Generates Additional Work – i.e., paperwork, subsequent
Investigation, etc.
  Supervisors and/or Workers have Not Been Instructed How
to Report Near Misses.
  Once reported – Nothing is Done to Address or Correct
what Caused the Near Miss.
  Near Misses are so Frequent that they become common
place and part of the everyday work life.
Reasons Why Our People
are Reluctant to Report
NEAR MISSES
  Upon reporting – there is No Follow-up Communicated
to the Individual(s) who so reported the Near Miss.
  Form(s) Used may be too Complicated for Near Miss
Reporting.2
  There is No One Assigned to handle / direct the
actions needed to correct what caused the Near Miss.
  Workers have the Mindset that being Safe in the Workplace
also includes Being Lucky.
  There is No Motivation for Organizational Employees to
report Near Miss Incidents – nothing is gain Individually or
Organizationally.1
22 David Patzer, DKF Solu3ons Group, LLC 6/12/12 Reasons Why Our People
are Reluctant to Report
[email protected] 707/373.9709 cell or 707.647.7200 fax NEAR MISSES
  Employees may Fear a Possible Job Loss or
be Penalized – if they are found to be a
contributing factor of the Near Miss Incident.
  Loss of Credibility for those that report
such – may be viewed as a “Squealer.”
  Workers believe that their Supervisors will
hold such Near Miss Reporting against
them.
How to Increase Near Miss Reporting
  In order to answer this question, we have to
understand four things:
 
What is a Near Miss?
 
Why Do We Need to Report Near Misses?
 
How Do Accidents and Near Misses Happen?
 
What Are the Barriers to Reporting Near Misses?
Now We Can Answer The Central Question
23 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax It is
essential for
Supervisors
and
Managers –
to hear and
know about
Near Misses
How to Improve Near Miss Reporting
There are four important factors that must be present to ensure
that Near Misses are reported –
1)  There must be a Near Miss Reporting System in place that
tracks the status of.
2)  The Near Miss System must be understood by All Employees.
3)  All Near Misses should be investigated and corrective actions
taken if necessary to prevent their reoccurrence and/or more
serious Injury.
4) NO PENALTY – There should be No Penalty what-so-ever to any
Employee that reports a Near Miss.
 
As soon as such is experienced – all Near Misses will go underground.
24 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Improve Near Miss Reporting
  Just Culture:
  A just culture recognizes that competent professionals make
mistakes and acknowledges that even competent professionals
will develop unhealthy norms (shortcuts, “routine rule
violations”), but has zero tolerance for reckless behavior.
Is There A Difference?
•  Normal human error and a deliberate
violation of rules/policies/procedures?
–  Does your Discipline Policy recognize this
difference?
•  Pushing the limits of rules/policies/
procedures and a deliberate violation of
rules/policies/procedures?
–  Example: Driving
–  Does your Discipline Policy recognize this
difference?
If Your Organization doesn’t OFFICIALLY recognize the difference, will
people trust it enough to report errors/mistakes/near misses?
25 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Managing Risk – The Three Behaviors
•  Three types of behavior can be involved in
error:
–  Human error
–  At-risk behavior
–  Reckless behavior
•  Each type of behavior has a different cause,
so a different response is required.
Managing Risk – The Three Behaviors
Normal Error
At-Risk Behavior
Product of our
current
system design
Unintentional RiskTaking
Reckless
Behavior
Intentional Risk-Taking
Manage through:
Manage through
changes in:
•  Processes
•  Procedures
•  Training
•  Design
•  Environment
•  Coaching
•  Understanding our
at-risk behaviors
Manage through:
•  Disciplinary action
•  Removing incentives
for at-risk behaviors
•  Creating incentives
for healthy behavior
•  Increasing situational
awareness
26 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax The single greatest impediment to
error prevention in the medical industry
is
“that we punish people for
making mistakes.”
Dr. Lucian Leape
Professor, Harvard School of Public Health
Testimony before Congress on
Health Care Quality Improvement
27 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Create a Safety-Supportive Policy
•  State the Purpose
•  Draw the Bright Line
•  Set the Expectations
SUBJECT:
HOSPITAL WIDE POLICY
Policy #:
6.350
Page#:
1 of 3
Origination Date:
Reviewed:
6/03
NON-PUNITIVE CULTURE
5/03
Revised:
PURPOSE
To encourage reporting of adverse medical events, near misses, existence of hazardous
conditions, and related opportunities for improvement as a means to identify systems changes
which have the potential to avoid future adverse events. To provide guidelines for the
application of non-punitive processes versus disciplinary actions.
POLICY
PVHMC encourages reporting of all types of errors and hazardous conditions. The
organization recognizes that if we are to succeed in creating a safe environment for our
patients, we must create an environment in which it is safe for caregivers to report and learn
from errors.
It is recognized that competent and caring associates may make mistakes and it is the
intention not to instill fear or punishment for reporting them.
There must be a non-punitive, supportive environment for all staff to report errors and near
misses.
Error and near miss reporting are a critical component of the PVHMC patient safety and risk
management program.
Errors and accidents should be tracked in an attempt to determine trends and patterns to learn
from them and prevent a reoccurrence, thus improving patient safety.
The focus is on how systems and processes can be improved to help people avoid mistakes in
the future
In the process of evaluating errors and near misses, healthcare providers participate in
reporting and developing improved processes
GUIDELINES
The focus of the program is performance improvement, not punishment.
Employees are not subject to disciplinary action when making or reporting errors/injuries/near
misses except in the following circumstances:
The employee repeatedly fails to participate in the detection and reporting of errors/injuries/
near misses and the system-based prevention remedies.
There is reason to believe criminal activity or criminal intent may be involved in the making or
reporting of an error/injury.
False information is provided in the reporting, documenting, or follow-up of an error/injury.
The employee knowingly acts with intent to harm or deceive.
Reckless acts
SPECIAL NOTE:
Inconsistency of Just Policy application is a
common killer of a safety culture
Bottom Line About Just Cultures:
•  Console the human error
•  Coach the at risk behavior
•  Punish the reckless behavior
•  Independent of the outcome.
28 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Improve Near Miss Reporting
In addition to these Factors – there are other
important elements that should also be in place –
  DRIVER OF THE SYSTEM – At each of your
Locations – you need to have someone assigned to
be the “Handler” of all Near Misses.
 
Such duties will include Recording, leading the Near
Miss Investigation, and helping to determine and
complete Corrective Actions to prevent any
reoccurrence.
How to Improve Near Miss Reporting
In addition to these Factors (con’t) –
  PUBLICIZE YOUR EFFORTS – In order to make Near Miss
Reporting successful – you must Publicize Your Efforts.
 
 
You need to find a way to report how corrective actions taken as
a result of Near Misses – have helped the Organization and your
People – by making their Workplace Safer.
You will have People reluctant to report Near Misses – until they
see that they have something to gain from so reporting.
  SHARE WITH OTHERS – Near Misses can and should be a
Learning Tool for all applicable Organizational Employees.
 
Make sure that you take time to not only share the Near Miss
Incident – but also how it occurred and what actions were taken
to prevent its reoccurrence.
29 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Improve Near Miss Reporting
In addition to these Factors (con’t) –
  COMMUNICATE ACTIONS TAKEN – It is very important that you
communicate any findings and actions taken to those involved with the
Near Miss.
 
 
This includes both the Individual(s) that reported the Near Miss – as well as
any Individual(s) that were actually involved in the Near Miss.
In addition, it would be beneficial to advise any Work Group Members that
are involved in similar work actions.
  USE AS A LEADING INDICATOR – Take time to track and record your
Near Miss Incidents. Such can be used as an indicator of your Safety
Performance to come.
 
 
Various factors can be interpreted from Near Misses including – are they
major vs. minor in nature, is their primary cause from either lack of
awareness or lack of training, etc.
Near Misses can point to what Safety Efforts are needed in the Workplace –
to address what is causing them – and any negative trends in Performance
How to Improve Near Miss Reporting
In addition to these Factors (con’t) –
  SENIOR MANAGEMENT SUPPORT – Sr. Management must
support Near Miss Reporting in three aspects –
 
 
 
 
First – it must support the Process of Near Miss Reporting and
expect it to be an integral part of the Company’s Safety Efforts.
Second – it must understand Near Miss Reporting and not react
negatively to a spike in Near Misses reported for a particular area.
Third – they must know and accept that there is a Cost to Near
Miss Reporting – such as the time needed to track and correct,
incident investigation, etc.3
Sr. Management must let the necessary actions play out that
should address any need that may be creating Near Misses.
30 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Sample Near Miss Reporting System
  At the end of EVERY shift, ALL employees are
required to complete an anonymous (if they want)
Safety Card.
  Safety Card results are tabulated for trends, near
misses (for follow up investigations).
  This allows for constant monitoring of LEADING
INDICATORS and NEAR MISSES.
  Example
31 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected]u3ons.com 707/373.9709 cell or 707.647.7200 fax Summary: Near Misses ID Weakness
These Activities/Metrics Allow You To Change Course and Make Too Late
Adjustments BEFORE Something Bad Happens
Leading
Indicators
Attitudes
(set up conditions,
behavior)
- Perception
surveys
Program
Elements
- Training
- Accountability
- Communications
- Planning &
Evaluation
- Roles &
Procedures
- Feet cleaned/tv’d
Physical
conditions
-Inspections
-Audits
-Risk
assessments
-Prevention &
control
Behavior
(action)
-Observations
-Near Miss
Reporting
-Feedback
loops
Lagging
Indicators
Measures
Results
- Accidents
- Incidents
These are BARRIERS to Accidents/Near Misses
Without Measurement, There Cannot Be Management
Once Near
Misses are
reported –
what will
You Do
with them?
32 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Actions Needed to Address NM Reporting’s
The Actions
that we take in
response to
Near Miss
Reporting’s –
will determine
how successful
this Process
will be.
Actions Needed to Address NM Reporting’s
ACTIONS IN
RESPONSE
EXPLANATION / COMMENTS
KISS
Keep your actions Simple. Actions taken in
response to a NM Reporting – should be
basically a Streamlined Accident Investigation.
Act On in a
Timely Manner
The severity of the Near Miss Incident – should
dictate the type / level of response and the
corrective actions taken and when.
Upon being informed of a Near Miss – make
Communicate
sure that you or someone advise those so
Actions Needed
reporting – what actions will be taken & when.
Use as a
Learning Tool
Your actions taken in response to a NM – should
be to Learn from the Incident – and take actions
to prevent any future or further events.
33 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Actions Needed to Address NM Reporting’s
ACTIONS IN
RESPONSE
EXPLANATION / COMMENTS
As noted above – Near Misses should be
Don’t Take Near considered a “Do Over.” By not giving the
Misses Lightly appropriate response to – could result in an
Actual Injury next time such events occur.
Hold Someone With Near Misses – I would encourage you to get
Responsible to your People involved in the corrective actions
needed – such as the Supervisor in charge.
Act On
Follow-up
As with any Safety Issue – Follow-up is critical to
the success of your Safety Efforts – and from
preventing Near Misses from becoming future
Accidents that Injure Your People.
Actions Needed to Address NM Reporting’s
ACTIONS IN
RESPONSE
EXPLANATION / COMMENTS
Act with Your
People in Mind
Especially with Near Misses – your People will
be watching. If the reaction to is insignificant to
correct possible Safety Problems – does you
inaction communicate acceptance on your part?
Near Misses that are experienced within your
Talk about Near Organization – should be discussed openly with
Misses Openly Your People – so that all can learn from such
Incidents and be Safer as a result of.
Communicate
Your Findings
and Actions
Take time to communicate what was found to be
the Cause of Near Miss Incidents – and what
Corrective Actions were taken to address.
34 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Actions Needed to Address NM Reporting’s
Near Miss
Incident
Root Cause(s) are
Determined
Corrective Actions
are Taken to
Prevent
Reoccurrence
Reported to
Supervisor /
Safety Leader
Near Miss
Incident is
Investigated
Near Miss Event
and Actions are
Recorded
Near Miss
Incident Report
Completed
Safety Leader
Reviews for
Severity
Near Miss
Corrective Actions
are
Communicated
Suggested Flow Chart of Near Miss Actions Needed
Example of a Near Miss Report
Workforce Safety & Insurance – www.WorkforceSafety.com
NEAR MISS REPORT
A near miss is a potential hazard or incident that has not resulted in any personal injury . Unsafe working conditions,
unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause
work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents
immediately. Please complete this form as a means to report these near-miss situations.
Department/Location ________________________ Date: ________________ Time __________ am / pm
Please check all appropriate conditions:
____ Unsafe Act
____ Unsafe Condition
____ Unsafe equipment
____ Unsafe use of equipment
Description of incident or potential hazard: ____________________________________________________
__________________________________________________________________________________
Employee Signature _____________________________ (optional)
Date ___________________
NEAR MISS INVESTIGATION - Description of the near-miss event / condition:
___________________________________________________________________________
___________________________________________________________________________ Causes
(primary & contributing) ___________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Corrective action(s) taken (i.e., Remove the hazard, replace, repair, or retrain in the proper procedures for the task)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Signed _________________________________________
Date Completed __________________
Not completed for the following reason: _____________________________________________________
Management ________________________________________ Date ___________________________
http://www.workforcesafety.com/safety/sops/NearMissReport.pdf
35 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Actions taken
in Response to
Near Misses –
will often
dictate the type
of Accidents
Your
Organization
Incurs
Keep the Process Flowing
The following Suggestions are offered to help ensure the
Success of your Near Miss Reporting Program –
  Near Miss Reporting, Investigation, and Corrective Action
– should be considered an INTEGRAL PART of your
Organization’s Safety Program.
  Be CONSISTENT with your response to and actions
taken regarding Near Miss Incidents.
  Near Miss Incidents that are severe in nature – should
receive as much ATTENTION and CORRECTIVE
ACTION as an actual Accident / Injury.
36 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax Keep the Process Flowing
The following Suggestions are offered (con’t) –
  Put out the Message to all of your People – that Near
Miss NON-REPORTING is UNACCEPTABLE.
  COMMUNICATION of both Near Miss Events and the
Corrective Actions taken – will be the key to its success.
  The Reporting of Near Misses – should NEVER BE
INCENTIVEIZED. Let the Program prove its merit.
  Employees should NEVER BE PENALIZED for reporting
Near Miss Incidents.
Keep the Process Flowing
The following Suggestions are offered (con’t) –
  LEARN – LEARN – LEARN – from your Near Miss
Incidents and be Safer because of them.
  Any and all Near Miss Incidents should be SHARED
WITH OTHERS. Let others Learn too.
  As with any Safety Effort – REVITALIZE from time
to time to ensure such matches current Processes.
  Engage your ENTIRE ORGANIZATION in your
Near Miss Reporting. Senior / Local Management
should know about Near Misses as well.
37 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax How to Increase Near Miss Reporting
As Supervisors
and Managers –
we must work
with our People
to see events,
conditions, etc. –
BEFORE they
turn into
Accidents &
Injuries.
How to Increase Near Miss Reporting
Supervisors and
Managers – Must
be there for
their People –
including those
that Do and Don’t
know better.
38 David Patzer, DKF Solu3ons Group, LLC 6/12/12 [email protected] 707/373.9709 cell or 707.647.7200 fax David Patzer
[email protected]
I welcome your Comments.
39