It cannot be assumed that workers will naturally begin to report problems, errors, and near misses once a just environment is in place. There are a number of organizational as well as psychological barriers that must be hurdled before a reporting culture can be put in place. The first barrier to overcome is
- a natural disinclination to confess one’s blunders — no one wants to be held up to ridicule.
- The second barrier is the suspicion that such reports might go on the record and count against them in the future.
- The third is skepticism. People reason that if they go to the trouble of writing an event report that reveals system weaknesses, how will they be sure that management will act to improve matters?
- Fourth, writing the report takes time and effort, and many conclude, “why bother?”.
Following are some features of successful reporting programs. Each feature is designed to overcome one or more of the abovementioned barriers.
- De-Identification – How this is achieved depends on the culture of the organization. In some organizations, there is complete anonymity. Elsewhere organizations are content with confidentiality, wherein the person reporting is known only to a few people.
- Protection – A senior manager issues a statement that guarantees that anyone who reports will receive at least partial indemnity against disciplinary procedures. Because some acts are culpable, offering complete immunity from sanctions is not feasible. Experience from successful programs indicates that circumscribed guarantees are sufficient to elicit many reports of honest errors.
- Separation of functions – Successful programs separate the functions of collecting and analyzing the reports from the authority to initiate disciplinary proceedings.
- Feedback – Rapid, useful, accessible, and intelligible feedback to the reporting community is essential to overcome any perception that reports were going into a black hole. This may be achieved by publishing summary reports of the issues raised and the measures that have been implemented.
- Ease of making the report – Experience shows that people prefer responding to a reporting style that allows them to tell a story and express their own perceptions and judgments instead of forcing responses into a highly structured preprogrammed format.
The greatest value of a safety information system lies in its ability to identify recurrent event patterns, error traps, and gaps or weaknesses in the controls. Reporting systems are usually coupled with corrective action programs wherein identified problems in the field are researched and plans are devised. Actions are carried out to eliminate the problem and prevent a recurrence. A primary objective of acquiring this safety information is to help the organization (workers, leaders, and management) learn from past near misses, mistakes, and inconsequential errors.
