Incident Reporting: Challenges & Opportunities
By Samantha Gruskin, firstname.lastname@example.org
Working in stage management across a variety of theatres, I was always underwhelmed by the standard of incident report. In many instances, the report form didn’t exist. If it did, it was totally inadequate, or sat on someone’s desk unconsidered. Although sometimes blown off as just another procedure, incident & near-miss report forms are valuable tools that when acted upon properly, can directly improve the safety of a working environment. I saw there could be a lot to gain by improving this area of procedure, and went out into the industry to find out what was getting in the way of effective incident report. Why did people not report and what would make them more likely to do so? What were the practical barriers? What were the cultural barriers? Looking into the working practice of theatre and speaking to practitioners directly, I found that we must address both the procedure itself and the culture surrounding it. The report form must be well engineered, but of equal importance is cultivating an environment in which reporting is encouraged and valued. Luckily, there’s a lot we can do to improve incident report, most of it requiring very little effort. There’s useful research in psychology about how the brain processes information related to adverse events and how we notate that on something like an incident report form. Simply by incorporating these principles, we can improve the data we get from the report. I joined that research with the practical experience of those working in the industry, to come up with an understanding of what the issues are, what we can do better, and recommendations that anyone can apply to get the most out of their reporting procedure.
When I asked practitioners what they found most difficult about incident report, a common response was they felt that they needed to tell a story. Even if they weren’t sure of elements related to the event, or the cause, they felt they had to explain it. This is completely natural as the brain’s natural tendency is to form a narrative of information, especially when there’s been an adverse event and we feel there’s something to account for. Unfortunately, this need to form a narrative often results in the reporting of false information, which can taint the reliability of the data. The report should only concern factual statements, even if there is no clear link between them at the time. Assuring the respondent that they don’t have to connect the dots in the information they provide not only increases the reliability of the report, but puts them at ease, which also addresses the issue of anxiety brought about by blame culture.
Unfortunately, fear and blame culture are among the first things that come to mind when incident report is discussed. In a comprehensive Norwegian study, “fear of disciplinary action as a result of blame culture, or of other people’s reactions” was listed as the first of five primary factors in why people do not report. Speaking with stagehands and technicians across theatres in London, the same was true in my findings. Members of an organization are afraid to report because of either the managerial or social implications. This is perfectly understandable, but unfortunate. The purpose of incident is not to point a finger, but to understand more about the working environment so that safety can be improved for all. While incident report relates to negative events, it is ultimately a positive thing. This purpose should be clearly explained to the respondent in the instructional text. Blame culture is the largest barrier to effective report, but in the end, it’s only a matter of perception. Framing the report as blame-free and adopting this tone throughout the text is an important first step in de-pressurizing the situation. If a respondent understands that the information they provide only serves to improve the working environment, and will not result in the allocation of blame, they will be more comfortable and less defensive in completing the form which will then encourage a more thorough response.
In addition to the tone, the actual content of the form can be curated to produce the most accurate response. Remembering the specific details of an event is extremely important, but surprisingly difficult. This act of remembering carries a large cognitive burden for the respondent, especially if they’re emotional or stressed. This difficulty in remembering a complex event can result in the report missing valuable pieces of data. However, the respondent can be given retrieval cues to help them access memories related to the event. For example, asking the respondent to think about the environment in which the event or near miss took place, the materials involved or the work activity going on at the time can help them access memories related to the event. Asking these additional questions helps the respondent remember essential information relating to the occurrence — information that might have remained dormant had the form only asked “what happened”?
Asking about the environment of the event also helps uncover systemic, managerial and environmental underlying causal factors which are notoriously difficult to capture in incident reports. Managers have a tendency to neglect the fact that human behavior is always influenced by the environment in which it occurs. This tendency to focus on individual failings and human error, rather than situational factors, ultimately disservices the employee and organization. Suppressing issues in the environment and working culture that may have contributed to a near-miss might, when left unchecked, result in an occurrence of an adverse event. Whether it’s asking about the adequacy of the work space, the level of light, or the time pressure associated with the job etc., a consideration of these factors is essential in the report form.
Near-misses and minor incidents offer a unique opportunity to identify potential hazards in the working environment before any major incidents occur. However, there is only a singular chance and limited time to collect this important information. To this end, it is in the best interest of everyone in a producing organization to have the most well-developed incident report procedure possible. By optimizing these forms and incorporating the research mentioned above, we can create better personal awareness for the practitioner and better procedure; procedure which ultimately protects those doing the work, so they can carry on doing it.