Incident reporting example

Dear Colleagues

From time to time I like to share examples of good investigations with a view to helping other reporters get ideas on how to improve their investigation methods. With permission from the reporter, I have posted this anonymous report. At the last Face to Face SHOT symposium I gave a presentation (attached in a different forum thread) on taking a top down approach to investigating events which provides a process for addressing weaknesses in the existing quality system. This approach guides you through assessing the design of a process, ensuring the procedure is thoroughly documented and trained out to staff. It also looks at addressing environmental issues and staff capacity so the entire quality system (human factors) is addressed before addressing any individual staff slips or lapses (human errors).

[COLOR=#242424][FONT=&quot]Please be aware that investigations must have [/FONT][/COLOR][COLOR=#000000][FONT=&quot]taken care to ensure that process, procedural or system-based errors or problems have not been overlooked.[/FONT][/COLOR][COLOR=black][FONT=&quot] [/FONT][/COLOR][COLOR=black][FONT=&quot]Once the investigation has been completed then any causal factors must be addressed, s[/FONT][/COLOR][COLOR=#000000][FONT=&quot]uch as if distractions have been identified then these distractions must be addressed in the CAPA to avoid reoccurrence.[/FONT][/COLOR]

I have shared this presentation with a number of reporters individually before and have seen it used in a number of reports shared on SABRE. This is one of those reports.

Thanks

Chris