Incident Reports for Risk Management

What is an incident report & why is it necessary?

An incident report is a formal record of the facts related to an accident, near miss or injury. This document is an integral part of risk management, (particularly the management's response and monitoring & control stages of risk management). Its primary purpose is root cause analysis (aka fishbone diagram analysis), ie to discover the circumstances that led to the occurence of a risk so as to prevent future incidents.  

Incident reporting is NOT intended for comparisons. For instance, if different reporting units are compared for safety based on incident reporting volume, a unit with more reports of adverse events may be incorrectly marked down when, in reality, the converse may be true. For instance, that unit may simply be more vigilant, have a better culture regarding safety-consciousness and preparedness for submitting reports. That unit may well be conducting more double checks than its counterparts.

Incident reporting is NOT intended for measuring performance (like safety, brand awareness, etc) like number of medication errors issued by a hospital to determine that hospital's safety. As seen from the earlier example that highlighted why a high volume of incident reports is not necessarily the sign of bad performance, incident reports are much better for identifying risks and root cause analysis. Besides, statistics show that just over 5% of all adverse events in health care are reported at all. In other words, units with more reports of adverse events are possibly more worthy of one's trust.  

Incident reporting is NOT intended for tracking the changes over time of reporting. This is due to reporting bias. For instance, the healthcare industry sometimes saw very significant increases in reports after its communities implemented improved reporting systems. As the earlier discussions already illustrated, a higher number of reports does not necessarily denote higher risk levels.

The contents of an incident report

As recommended by SafeSite Solutions, EVERY incident report should have the following as a minimum.

• Type of incident 
• Events with an undesirable outcome: injury, property damage or theft
• Events with no undesirable outcome, this time (because a hazard was exposed): near miss
• Location of the incident (and or any other context-specific detail that might determine liability. While 'location' is useful for OSHA-type reporting for protecting workers in the workplace, conditions in which products and services are used may require other customized fields.)
• temperature (if it is a factor that ensures and determines safe use, like temperature logs of meat storage facility where meat went bad and caused illness) 
• Date of incident
• Time of incident
• Name of an affected individual * (Also include qualifying details related to individual's membership in a population, segment, etc of at-risk individuals)
• Jane Donut, aged 5 (if age is important to segment definition) 
• A narrative description of the incident, including the sequence of events, results of the incident and response.* (Considering the definition of 'risk' where a deviation occurs from the expectation and the concept of an 'inciting event' that changes the normal business as usual course of any story that would have been otherwise too uneventful to tell, describe the event from which the deviation occurred.) 
• Example: Hazel's X-blade scissors fell from her desk onto her lap (the 'inciting event' described plainly and objectively) while she was stitching an item A25 (the normal story that would have been too uneventful to tell otherwise). Suspecting a deep lap wound, her boss (Jackie Mason) called 911 (business representative's response). Hazel reported feeling a sudden and overwhelming feeling of exhaustion that made her "nod" for a second. (The version of the injured party). 
• Description of Injuries, if any & severity in terms of the business context. 
• Example: broken right index finger. Injury will require at least x weeks for recovery, resulting in downtime in the typing role for that period.
• Example: Bruised forehead. Jim returned to work within 5 minutes. 
• Treatments required, if any
• Witness name(s)
• Witness statements
• Other workers involved
• Video and/or 360-degree photographs of the scene

Add contextually relevant items like the following.

• Whether or not proper personal protective equipment (PPE) was being used
• The root cause(s) of the incident
• Associated hazards raised and resolved following the event
• The affected individual’s version of the events
• Actions taken by concerned individuals after the incident

Key Considerations

*Create a separate report for each individual even if more than one person is injured. While it is acceptable to duplicate general details across reports of this nature, each report will need details specific to each individual, like the event from their point of view or medical records.

*Include quantifiable measurements where possible. Example: The ladder capacity is 250 lbs and the victim was hoisting 300 lbs.

Review good samples of incident reports on SafeSite Solution's website.

Best Practices for Implementing an Incident Report System

• Design the reporting system to provide value to risk management. The system should be able to generate in-depth analysis and result in strong interventions to reduce risk. A very well designed system has several versions of the incident report. For instance, one version is specifically designed for near misses, falls, behavior incidents, specific types of injury, etc. 
• Encourage all persons to report all incidents, however small, even if "nothing happened!" (aka a near miss). 
• Make the process meaningful to the reporter (as a means to incentivize their best use). Allow the process to give reporters a sense of empowerment. Really stress appreciation for the reports. Follow up on reports to show that the reporter's time was not wasted.
• For instance, allow incident reporters to recognize that they are contributing to the improvement of the product or service they sell.
• Foster a no-blame approach to reporting. Where that is difficult, consider making the reporting process anonymous.
• Make the process as simple and convenient as possible. 
• Some templates offer electronic contact forms. 
• Electronic forms have become popular. The OSHA offers Excel spreadsheets with fields that can be filled in over time.
• Consider your reporters. If they are the type of people that will be turned off of completing incident forms, consider another medium they are more likely to use, perhaps a telephone number they call so that someone else completes the form. 
• Define the event as well as possible.
• Injury, near miss, etc  
• Define the at-risk population as well as possible. Example: A market has segments like children below 5 that are at risk of injury for products with certain features like harsh chemicals. 
• Consistently monitor the at-risk population, especially if it exhibits risk-inducing behavior.
• Encourage persons writing reports to be objective and to avoid blame games. Mangement's response should show gratitude for the chance to implement measures to prevent similar events in the future.

Integrate Incident Reports into your Risk Management

• Identify and assess the hazard(s) 
• Identify the risk(s) whose occurrance it is a possible or even probable cause (using root cause analysis example using a fishbone diagrams)
• Considering the level of exposure of the hazard and the consequent probability of the risk, (re)assess the risk rank.
• Adopt the appropriate risk response.

CONTENT RELATED TO INCIDENT REPORTS FOR RISK MANAGEMENT

• Risk management 101
• Hazards 101
• Other types of risk management risk documents include checklists.
• SafeSite allows you to signup for a free or paid account. They offer many resources that promote worksite safety like incident report examples, templates, checklists, workflows, inspections and so on.
• Free downloadable and customizable templates (SafeSite)
• A near miss aka close call, near accident, accident precursor or injury-free event is an event that could have been an accident had things played out differently. It occurs because of exposure to a hazard like a nut-flavored snack, a hazard (for those with nut allergies) is unlabeled and provided as free samples to the public. Thinking the item is nut-free, the public is exposed to the hazard and persons prone to anaphylaxis begin to sample it, thereby running the risk of anaphylaxis. A near miss report should lead to hazard resolution and preventative measures. In this example, the hazard resolution involves labeling the snacks or removing them from the reach of the public. However, if the event isn’t reported or addressed, a serious injury could easily result, possibly only hours later from the same or similar circumstances. Other examples include nearly getting Covid-19 by wearing inadequate protective personal equipment (PPE).

   

Notes:

Occupational Safety and Health Administration (OSHA). With the Occupational Safety and Health Act of 1970, the US Congress created the Occupational Safety and Health Administration (OSHA) to ensure safe and healthful working conditions by setting and enforcing standards and by providing training, outreach, education and assistance.