A colleague was proudly boasting that her service had a really low level of accidents and incidents since she dispatched a member of staff who had been involved in a situation where both he and the service user he was supporting had ended up injured. The story was that this individual had featured in lots of incidents and my colleague felt that she had now identified the source of the problem and ‘fixed it’.
I wondered at the time if this could be viewed another way; what if the incidents were continuing, but reporting had reduced since fellow workers had seen one of their number sacked ? What if the chap concerned had not been the cause of the series of events, but just the hapless victim? And what if the workplace itself was at fault?
We need processes and systems to assure ourselves that staff are acting correctly and to give employees the security of knowing they are working safely. These systems of work can come about in a number of ways. Often we are given few choices about how things should be done; medicines administration is a good example. We often recreate work processes based on historical methods or prescribed routines.
When things go wrong, I believe it is good practice to review the systems of work in operation at the time, and the training and skills of the people using them, before you apportion blame. Using a root cause analysis method, for example, will highlight the numerous causal factors at play in an incident, from the environment (too noisy to concentrate, faulty equipment, illegible handwriting) to the process (too many steps, complex recording, inefficient methods of work) It also allows you to consider things like organisational culture and staff behaviour, team working or the lack of it. I have used dozens of Root Cause Analysis exercises and I can honestly say that the main culprit in any incident is rarely the poor soul who was at the wrong end.
It’s a wild idea, but why not involve the team in analysing incidents at work and then involve them in making changes to systems or training, to eliminate future errors? Use their experience of the shop floor to help find cleaner, simpler and, above all, safer ways to carry out day to day activities. You never know, you might learn something new too!
