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MartinL

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Content Article Comments posted by MartinL

  1. Well done for highlighting the issue.  

    There is always a reluctance of humans to report things that are “not right”, and lots of my research has been about getting people to report incidents (accidents, near misses, security concerns). If things are not reported all that lovely data (evidence) that could be used for change is not available. No data = No appropriate change.

    The biggest barrier to reporting is feedback, and what our – oh dear – many, many studies show is that unless the feedback is immediate, appropriate, and the input appears valued, then people don’t report. Part of that feedback, in the longer term ,is evidence of change – or explanations of why things have not changed.

    Our work in getting people to report issues as soon as they see them is extensive. While success brings a warm glow to us science types – often many thousand percent increase in data in some cases, this can cause an issue possibly relevant to healthcare. I recall a heated debate where the number of incidents reported in a domain rose from 7 per month to over 300. The client was not happy – incidents, they said in a loud voice, have increased massively and we did not pay you to increase the number of accidents! Being a science type, I explained that the number of incidents was the same, you just know about them now. It took a lot of time for them to understand the difference. 

    Simply, No reports, No data, No science, No change.

    You also highlight that the investigation was not immediate – so I’ll get the ‘When to investigate' blog done soon.  I’ll also do something on getting people to report.

    Again – excellent post, if you see it, say it, and keep saying it until its sorted.  Your Human Factors community are there to support you. If someone gives you "it’s a governance issue" or even worse this is "root cause analysis", "it takes time" or "t’s a process", or you "lack the training" then simply ask – what’s my motivation to report another similar incident that’s occurs a few days later? 

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