Discuss the reasons why some employees in some organisations do not report accidents and near misses and discuss ways in which these organisations could improve their level of reporting.

Introduction

Because of scientific and technological advances we live in a world of increasing specialisation, with complex inter-related working practices and inter-dependence on others’ services and products. As a result we have to rely on ourselves and others to minimise injury or harm workers, customers and the public at large. While To err is human: to forgive is divine (Pope 1711), and errors are an unavoidable fact of life, we the public as well as the government expect that organisations take all reasonable steps to minimise the number of accidents that occur to employees, customers or third parties. Health and Safety at work is a significant problem and a review in 1995 (Jones and Hodgson 1998) showed that over two million people in the UK were suffering from illness thought to be caused by work. Findings such as these led the Government to implement further action plans on improving safety in the workplace (Department of Health 2000a). Another area that has been the subject of attention is the healthcare industry. Adverse outcomes in healthcare have been estimated to occur in up to 10% of hospital admissions (Department of Health 2000b). This together with the finding that there are high levels of under-reporting in healthcare (Stanhope et al. 1999) have resulted in the government setting up the National Patient Safety Agency one of whose primary aims is to improve reporting, learn from past mistakes and thereby have a safer healthcare system. Severe errors with large scale loss of life, such as plane crashes, focussed the efforts of the aviation authorities to develop strong safety-orientated practices with excellent results.
An understanding of how organisations operate to reduce the frequency of accidents is necessary before discussing the problems with reporting. Risk management is a system whose aim is to avoid accidents (defined here as an adverse outcome). To do this as effectively as possible involves gathering information on accidents and near misses (defined as an event, differing from normal standard operating procedural working practice which, although not resulting in an adverse outcome could, under slightly different conditions, have done so), analysing the surrounding factors which contributed to the event, and acting on the findings. Successful risk management results in fewer accidents. The components of the risk management process consist of key elements: reporting, investigation and action to ensure that the likelihood of future occurrences are minimised. Therefore for this process to operate successfully the key initial component is a robust reporting system. However, it is best not to view the reporting element in isolation, as the factors that affect all elements in a functional risk management process, both incentives and barriers, are inter-related and reports of accidents or near misses that are not appropriately dealt with via detailed investigation and action, are at best useless and at worst can reflect an organisational culture that is careless about improving safety.
To understand the factors that influence reporting in different organisations it is necessary to examine the different component parts that together constitute the risk management process in highly effective organisations with a good safety record and to compare these with organisations with a poor safety record. By examining the process of data collection and how this is encouraged, as well as the patterns of investigation and action in flag-ship organisations and comparing these with the operations in others, the deficiencies in a failing organisation can be identified and understood. The way safety-oriented organisations implement and maintain desirable attitudes and behaviour in their workplaces are examined. Key themes which will be evident from comparing the risk management systems of successful, or safety-oriented, and failing organisations are the different attitudes, perceptions, understanding and behaviour of both the management and employees, and their interaction with, and understanding of, each other in these two settings. If these practices can be understood and adapted to operate in poor-performing organisations, then the expectation will be that this will lead to improved co-operation from employees in reporting, better risk management, and therefore a reduction in errors.

Discussion

As already indicated organisations have strong incentives to ensure safety for employees, customers and third parties. It is widely accepted that organisations have a moral and ethical duty to provide safe working environments for employees and safe services/products for customers. In addition, the occurrence of a serious accident which results in death or injury may lead to significant financial losses and even bankruptcy. To add to this there are legal obligations and guidelines which many organisations, notably the high risk organisations (for example aviation and nuclear power plants) must be complied with if they are to be allowed to operate (Johnson 2003). In the U.K. the Health and Safety Executive has the power to prosecute companies who flout Health and Safety laws.
In order to minimise the occurrence of accidents, by reducing elements that increase the risk of accidents, organisations utilise risk management policies. Risk management is the process whereby a company (both management and employees) operates a system which aims to ensure that accidents are avoided. The components of the risk management are reporting, investigation and remedial action to reduce the risk of future accidents. In addition, an organisation can learn from the reported events and foresee further accidents that are “waiting to happen” by analyzing the events leading up to the precipitating error in the reported event. In order to achieve this goal the first crucial component in the process is a robust reporting system whereby all members of staff report all accidents and near misses to their supervisors or risk management teams. Clearly the first step in attaining the necessary information (namely the frequency and details of these events) is co-operation by the employees and a willingness on their part to contribute effectively by reporting all accidents and near-misses. If an organisation does not have good data about the incidence of accidents and near misses, then this undermines any attempts to identify and rectify elements that increase the risk of accidents occurring. While much has been written on analysis of risk, the processes of data analysis and system operations at the organisational level (Levenson 2004, Carroll Rudolph and Hatakenaka 2002), less is known about the barriers and incentives to making reports of accidents and near misses at the employee level.
At this point it is useful to clarify in more detail the difference between accidents, resulting in adverse outcomes, and near misses, which do not. Although near misses seem less important than accidents (at least in the immediate situation, as there are no immediate adverse consequences), they have, if investigated properly, great potential to teach the organisation how to reduce risk, and to unveil trends or patterns of failure. It is recognised that for each serious accident there are far more near misses, as demonstrated by the “Safety Pyramid” (Heinrich 1959), such that the serious accidents that come to light are just the “tip of the iceberg”. If it is possible to reduce the number of numerous near misses at the base of the pyramid this will have the effect of reducing the number of accidents at the top. This proactive approach to preventing and minimising accidents is more effective than simply a reactive approach. Near misses should be viewed as “free lessons” allowing the organisation to learn from the events preceding the near miss and to identify factors that contributed to it. Contributing factors, such as inadequate training or flawed operating procedures, can be reviewed and altered in order to minimise the risk of similar near misses occurring in the future. At this point it is worth noting too, that not all near misses will lead to accidents. Eliminating underlying causes of potential future accidents should reduce the incidence of them. Near misses can be viewed as potential accidents and by analysing the systems surrounding a near miss, any flaws can be addressed (Rose 2004).
While it is agreed that only a proportion of near misses are reported in a variety of organisations, the underlying reasons for reticence in reporting, and therefore poorer reporting rates vary from one organisation to another. One barrier to effective reporting is poor standardisation and terminology, so that employees are unclear about what constitutes a near miss or accident (Giles et al. 2006). Efforts to standardise terminology and develop national databases have succeeded for some high risk organisations, notably in aviation, and this has improved levels of reporting. However, national reporting, which is a valuable source of data and information, cannot supplant a local system of reporting and investigation, as the influence of local factors (that is the context in which the accident or near miss event occurs) can be overlooked at a national level (as these factors will differ from one location to the next), and investigation into the local context in which an accident occurs is crucial if appropriate remedial action is to be taken. Other local factors relate to the attitudes of employees, and these cannot be addressed solely by a national reporting system.
Cultural influences have been demonstrated to affect reporting patterns. Culture consists of a set of shared value systems and beliefs. Cultural influences operate at various levels, the most obvious being at the national level. Certain national cultural traits can affect the way reporting operates and have been shown to affect aviation risk management systems (Helmreich 2000). Examples of different national cultural influences are individualism (where individuals force their belief systems on others and question leadership), and collectivism (where individuals are more attuned to the group but are less willing to question those in authority). A common finding which affects the incidence of reporting is the cultural climate of the organisation, and the way in which the employees interact with and perceive management. Organisations in which management is committed to safety and which encourages communication and gives feedback to employees are organisations that do well in implementing an effective health and safety policy (Helmreich 1999). In order to do this they train employees about the importance of reporting and act on these findings, as well as provide feed back to the reporters and the relevant wider community on their actions. These activities positively reinforce a culture of reporting. However, other organisations, notably healthcare, have a different culture. In the medical arena the “person approach,” where errors are judged and reaction is punitive, dominates. Reason (2000) further explains that the “person-approach” demonstrates that organisations who act in this way are not cognisant of how to investigate a report correctly, as they stop probing into the background factors which set the scene for the precipitating event. Reason (2000) explains that these latent conditions (which can be defined as existing conditions, either environmental or human, that may interact with activities to precipitate an adverse event) if not recognised and remedied can lead to accidents in the future. If the organisation understands this approach and abandons the reactionary “person approach” then this will lead to a more proactive and thereby more effective risk management. The healthcare system tends to generate a culture of fear in employees who are therefore less likely to report accidents or near misses (either as a result of their own or a colleague’s actions). The “person approach” style adopted in the healthcare setting undermines attempts to improve safety, and this in part explains why levels of reporting are so low.
However, at the individual level there are other reasons why some groups are less likely to report near misses within the same working environment as others. These factors have been investigated by examining reporting patterns amongst different professional groups. Kingston et al. (2004) surveyed healthcare workers and found that nurses were more likely to report accidents and near misses than were doctors. These different patterns of reporting were explained by the different professional cultures in these two professional spheres. Nurses’ training and practice tends to be more protocol-driven than doctors, who operate more professional autonomy. Similar results were found in the study by Lawton and Parker (2002) who investigated the willingness of healthcare workers to report the mistakes of others. Although nurses had a higher rate of reporting than doctors, the level of reporting was low, reflecting in part the overall cultural ethos of the healthcare system. When reports of accidents were made they were most likely to be done when the outcome for the patient was bad and when the accident involved a violation of protocol. This, the authors suggest, reflects the need of the reporter to have strong grounds on which to report a fellow professional. Surprisingly, however, they also found that reporting was unlikely, even if the outcome for the patient was bad, if protocols were adhered to. This reporting pattern would lead to little or no reporting of adverse events where protocols were followed and as a result would not draw attention to a potentially flawed protocol with potential detrimental consequences on safety. These findings on the reporting behaviour of healthcare workers suggest the underlying causes are related to organisational and professional cultures, as well as training. A further study analysed the attitudes of different healthcare and aviation workers to identify personal factors that could contribute to the different reporting patterns between aviation (which has a long and successful record) and healthcare organisations. The findings showed that medical staffs were less likely to consider that fatigue affected their performance than were pilots. In addition, a flat hierarchy (where juniors are encouraged to question senior members of the team) was less well tolerated by certain groups in the healthcare setting (Sexton et al. 2000).
Other barriers that have been identified are that the effort of reporting can take up too much time and the perceived uselessness of doing so. Also, uncertainty as to whether a particular occurrence is suitable to report is also cited as a reason for not making a report. Schaaf and Kanse (2004) studied the reporting pattern in a chemical plant which had a strong safety culture and which experienced good levels of reporting. They were surprised to find that reports of self-made errors, even minor ones, were not made, nor were there many reports of self-made successful recoveries from self-made errors. To analyse why this was so, the workers were asked to keep a diary and to make a note of their recoveries from self-made errors. They were then asked whether or not (and why) they would normally report these events, and their responses were analysed. The results showed that the main reason for not reporting the majority of self-made errors was that there were no remaining consequences from the errors. This was a surprise to both the authors and to the management at the plant. This finding highlights the need for gaining and maintaining understanding from all members of the organisation about the significance of near miss scenarios, and clarifying which events need to be classified as accidents or near misses and therefore be reported.
For organisations to improve reporting levels from employees it is important to address the barriers as well as to introduce incentives to improve reporting rates. An excellent example of where reporting levels have increased is provided by the high risk industries such as aviation, nuclear and chemical plants. These organisations work in hazardous conditions and operate a strong safety culture. Because of this strong culture of looking for errors and emphasising a proactive approach, these industries have a good safety record. They recognise that accidents are not events that occur in isolation and therefore rather than take the “person approach” to accidents (which is blame-oriented and looks no further into investigating why the accident occurred), they have developed a “systems approach,” which concentrates on examining all the latent conditions which led up to the reported event. Such an approach recognises and, importantly, trains employees to understand that although human error is inevitable there are ways to change both the ways people work and the conditions under which they work in such a way as to minimise accidents (Reason 2000). One successful approach to address these issues was the development of an innovative method of training aviation staff with the view to increase safety called Crew Resource Management (CRM) training. CRM has the underlying purpose of providing trainees with the knowledge and skills to manage effectively the resources available for the work. The introduction of CRM represented a major change in aviation training such that, in contrast to traditional training which concentrated on the technical aspects of the job, other factors that affect safety were included. Trainees gained insight into the unavoidability of the risk of errors, why errors are made, and how to counteract these. Helmreich (2000) has shown that this type of training has been successful in changing the attitudes and behaviour of the workforce towards an active engagement in effective risk management. When the pilots’ experiences and perception of such training was surveyed, they felt that CRM principles and training were very useful particularly if integrated formally into the entire training curriculum (Beaubien and Baker 2002). So as this approach has been shown to affect reporting and behaviour in aviation organisations, a similar approach could be tailored to the needs of other organisations.
Other barriers to reporting also can be found at the individual level of the employee. One of these barriers to reporting is fear (Schaaf and Kanse 2004). Fear of losing one’s job or of being seen (and possibly victimised) as a whistleblower, as well as fear of litigation or criminal charges, can stop reporting even when serious accidents occur particularly in a punitive environment. Indeed, the combination of a hostile environment and fear can lead to attempts to hide the evidence and even to engage in denial (Sexton et al. 2000). These fears are not unfounded, particularly when in the setting of an organisation that takes the “person approach” when dealing with accidents. So in this scenario the personal barriers are compounded by adversarial organisational culture. In addition, the tendency for the public to apportion blame to an individual involved in an accident and the tendency for punishment to be meted out in proportion to the consequences or degree of harm which resulted from the accident, rather than in proportion to the severity of the error (Leape 2000), demonstrate the need for public education on the nature of accident causation (Evans et al. 2004). However, certain barriers to reporting such as fear can still operate even with optimal training of staff in an organisation that operates a “systems approach” to risk management. These problems have been addressed in high risk organisations. Often anonymity or de-identification of the reporter is guaranteed (in the absence of criminal activities) and in some reporting systems immunity from prosecution is offered (Barach and Small 2000). This protects the reporter and increases the level of reporting. However these principles may not be directly transferable to other organisations, notably healthcare, but it would be helpful if some reporter protection (such as anonymity) was introduced. This would be expected to improve reporting rates and ultimately, following detailed investigation, result in fewer accidents.

Conclusion

The lack of reporting accidents and near misses in some organisations poses a threat to safety, because in such a situation risk management cannot operate effectively. To address the factors that impair reporting at the organisational and individual level, comparison was made between highly effective and safety-aware organisations and organisations with a poor safety history. An analysis of how effective organisations operate the component elements of risk management demonstrates that in the case of the aviation industry improving knowledge, attitudes and behaviour of employees through training is paramount, and this generates an organisational practice, shared between management and employees, that values safety highly while striving to reduce errors. In addition, in order to bolster this organisational culture and promote the continual participation of employees, visible action and appropriate feed-back on reports are routine. It has been shown that the adoption of the “systems approach” to investigation of accidents in aviation, and the shared understanding of the nature of errors within safety-oriented organisations, is in sharp contrast to, for example, the healthcare setting where the environment is punitive and, from the perspective of improving safety, ineffective. These examples from successful organisations demonstrate that the barriers to reporting, such as lack of understanding and feelings of uselessness in making reports, are all effectively minimised or even removed. In addition, more personal barriers such as fear of reprisal and desire for anonymity have also been addressed in successful organisations, such as aviation, nuclear and chemical plants. They have achieved this in part because of their open communication styles and “systems approach” locally, but have also done so at a national level with the introduction of reporting schemes that protect the reporter’s identity and, in some cases, provide immunity from prosecution.
For failing organisations with a poor reporting and safety record, the first necessary step in addressing these problems is a willingness to improve and to learn. Without a strong desire to reduce errors any attempts to increase accident and near miss reporting will have little impact. Lessons can be learnt from studying the ways in which successful organisations set up and execute the key necessary elements of risk management. Key influences that can hamper or promote a strong safety culture and that are amenable to change, such as organisational culture and the understanding and co-operation of employees, can be improved through training. Issues such as making reporting easier to do (both in term of ease of use and relevance to the work setting) and protection of the reporter, are factors that need to be addressed and remedied. Stronger national cultural influences, of course, operate both outside and within organisations, and so public education is also required. If failing organisations were to implement risk management systems adapted from successful organisations, the levels of reporting of accidents and near misses would be expected to increase significantly, thereby enabling these organisations to become successful in terms of an improved safety profile. While To err is human; to forgive is divine is a famous quotation, this could perhaps be re-visited and applied in the health and safety setting under a modified version of the maxim, namely; “to err is human: to reduce the risk of error occurring is admirable and achievable”.