Analysis of Results from Event Investigations in Industrial and Patient Safety Contexts

Abstract

Accident investigations are probably the most common approach to evaluate the safety of systems. The aim of this study is to analyse event investigations and especially their recommendations for safety reforms. Investigation reports were studied with a methodology based on the characterisation of organisational levels and types of recommendations. Three sets of event investigations from industrial companies and hospitals were analysed. Two sets employed an in-depth approach, while the third was based on the root-cause concept. The in-depth approach functioned in a similar way for both industrial organisations and hospitals. The number of suggested reforms varied between 56 and 143 and was clearly greater for the industry. Two sets were from health care, but with different methodologies. The number of suggestions was eight times higher with the in-depth approach, which also addressed higher levels in the organisational hierarchy and more often safety management issues. The root-cause investigations had a clear emphasis on reforms at the local level and improvement of production. The results indicate a clear need for improvements of event investigations in the health care sector, for which some suggestions are presented.