[SystemSafety] Comparison of Confidential vs Non-Confidential Reporting Systems
Gareth Lock
gareth at humaninthesystem.co.uk
Wed Oct 17 14:59:51 CEST 2018
Hi Mike,
Aviation and confidential reporting works because there is a culture
that says reporting is good. It comes partly from the protection which
is afforded to crews for reporting. The FAA will reduce (remove) the
punitive sanctions if an ASRS report is made. The majority of countries
provide a level of legislative protection for evidence entered via a
reporting system, CVR or FDR.
Healthcare doesn’t have that. However, this report shows that you can
change practices and reduce litigation if you change behaviours towards
reporting.
https://news.aamc.org/patient-care/article/best-response-medical-errors-transparency/
(link out to a paper from there.)
In high-risk industries, bonuses are paid when the lost time
incident/fatality rates are low/zero. If a report comes in, then the
team lose their bonus. So it is ‘easier’ to hide the reports than
learn from them.
In addition to the reporting system, you have to have a Just Culture to
show it is ok to make a mistake, you have to have a learning culture
which means you look for others’ mistakes so you can improve your own
performance and you have to have a culture which provides feedback to
those who have reported to say what (if any) change can or will happen.
Reporting needs to be thought of as a system issue and not just a
platform for submitting things.
Regards
Gareth Lock
Director
M: +44 7966 483832
E: gareth at humaninthesystem.co.uk
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On 17 Oct 2018, at 13:49, Mike Rothon wrote:
> I am looking for some recommended reading on the respective merits of
> confidential and non-confidential (open?) reporting systems with
> respect to 'safety events'.
>
> Aviation is one sector that has generally embraced the confidential
> reporting approach, whilst anecdotally I hear that it isn't (yet) used
> so widely in the medical sector.
>
> In general, I am trying to understand why it is considered to be
> beneficial for aviation, but not necessarily elsewhere.
>
> For example, is it just a natural human desire to know 'who done it'
> [sic] that prevents wider adoption, or does the fear of being named
> and shamed encourage people to behave more 'safety consciously'?
>
> I have made the usual Google search, but with surprisingly few
> results.
>
> Thanks.......................Mike
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