The management of incidents, accidents and near misses is an important and critical component of risk management and safety within an organisation. Before discussing the significance of incident reporting, some definitions are necessary.
- An incident is a generic term defined as an unplanned event that results in, or may have resulted in, injury, damage or loss.
- An accident is an incident that has resulted in injury, damage or loss.
- A near miss is an incident that may have resulted in injury, damage or loss, but did not.
Incident reporting is also a component of incident management, which includes the immediate response to the incident, to remove immediate danger and to restore the facility to normal operation as soon as possible.
Incidents are an important signal to an organisation that the safety systems have failed. This may be indicative of an isolated deficiency in safety, or of more widespread organisational vulnerability to failure. In either case it is important to investigate the causes of the incident and its subsequent management, to reduce both the risk of further incidents and their impact.
For an incident reporting system to be effective, all incidents must be documented. This involves development and implementation of the following steps:
- An agreed definition of the events that are deemed to be incidents
- A scale of significance of the incident (for example the INES scale)
- A no blame culture that encourages reporting, rather than hiding of incidents
- A mechanism for reporting - preferable electronic (for example ROSIS)
Once the incident is documented, it must be investigated, analysed and reported to management. The report includes recommendations for changes in procedures, to reduce the risk of recurrence and/or injury or damage. These tasks should be the responsibility of an Incident Committee, which is a subcommittee of the Quality Improvement Committee. It is important that analysis of the incident is sufficiently detailed to identify the root causes which underlie incidents and initiate them. Using root cause analysis, it should be possible to determine all the steps leading from the root cause to the incident. In this manner, the root cause may be eliminated, or further preventative actions undertaken to reduce the risk that the root cause will initiate further incidents.
The associated links provide examples of incident reporting systems.