Widening the scope of incident analysis in complex work environments

Incident analysis is commonly used as a tooi to provide information on how to improve health and safety in complex work environments. The effectiveness of this tooi, however, depends on how the analysis is actually carried out. The traditional view on incident analysis highlights the role of human and technical failure in incident causation. More recently, the importance of the organisational factors underlying these human and technical failures has been acknowledged. Furthermore, incident analysis has traditionally focused on the failure side of incident causation, ignoring the potentialof human recovery in minimising the negative outcomes of the incident process. The recent emphasis on organisational failure has not vet resulted in any practical tools for detecting, describing and classifying organisational factors. The study outlined in this chapter presents the development of a taxonomy for classifying the organisational factors underlying incidents. The taxonomy was originally developed in the Dutch steel industry and has subsequently been applied in various settings in the medical domain. The application of the taxonomy in an Anaesthesia department and an Intensive Care Unit are discussed in detail. The analysis of recent incidents within these departments demonstrates both the contribution of organisational failures in incident causation and the contribution of human recovery in preventing minor incidents from developing into major accidents. The chapter concludes with suggestions on how to widen the scope of incident analysis in complex work environments, in order to raise its effectiveness as a tool for improving health and safety.