From: Ray Cook <raycook**At_Symbol_Here**APEXHSE.COM>
Subject: Re: [DCHAS-L] near-miss reporting form
Date: Wed, 13 Jan 2016 06:53:08 -0600
Reply-To: DCHAS-L <DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU>
Believing a near-miss is not an "incident" is the fundamental reason effective corrective actions aren't developed to prevent a future loss.
The "event" where things deviated from planned protocol is the "incident."
Once an incident occurs, you have little or no control over the consequences, which is why identifying the actual "incident" is so critical.
Variation in outcomes can range from no injury or property damage, to minor or major of each, lawsuits, regulatory action, bad PR, etc.
Once you recognize each event is an incident, then you will start to evaluate & correct them effectively.
Here is an example:
Think about a forklift moving a pallet with a drum of hazardous chemical on it. The driver turns while moving a bit too fast & it falls off the pallet. That is the incident. Regardless of consequences..
If the drum does not rupture or leak, then the consequence is no loss unless the driver is injured putting it back on the pallet. However, if the drum leaked & entered a creek near the facility, major consequences would occur. The event that occurred & the cause in both cases is identical, only the consequences were different. The corrective action should be the same for both outcomes, but seldom are, because one will be called a near-miss (if reported) & the other an incident.
As for using the data, there is a system to objectively quantify corrective action effectiveness, and you can actually cause incident reporting & effective cause resolution using it. And it is relatively simple.
Ray Cook, CIH, CSP
I Cor 1:18
Sent from my iPhone
I totally agree with Ralph, a good discussion ( for later) is needed on " what to do with the data and how to share?"
The difference with an incident is that there is no loss or ($=0)
> Date: Tue, 12 Jan 2016 20:23:03 +0000
> From: Ralph.Stuart**At_Symbol_Here**KEENE.EDU
> Subject: Re: [DCHAS-L] near-miss reporting form
> To: DCHAS-L**At_Symbol_Here**MED.CORNELL.EDU
> > >How about discussing how to define a Near Miss?
> The other question is what do you do with the information? I can see lots of potential uses, but it's unlikely that you'll gather statistically useful information with a random data collection system. People will have to see it being used usefully in order to be motivated to provide the information you're after. To me, this suggests that sharing the stories in a community honored way (i.e. prizes) is one possible use.
> - Ralph
> Ralph Stuart, CIH, CCHO
> Chemical Hygiene Officer
> Keene State College
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