The best software for quality and risk management.Anyone looking into incident analysis quickly ends up with a jumble of methods. Should you now choose TRIPOD because it is one of the most well-known methods, or does PRISMA suit your organisation better? And what do BowTie, SIRE, fishbone, 5 Why and all those other solutions do? In this article you will find some tips to help you on your way.
It is always annoying when an incident or near-incident occurs within an organisation. In many cases, the most natural reaction to this is to solve the problem and then quickly forget about it. This ostrich behaviour may offer a quick, easy solution, but does not lead to structural improvement. And this means that the same incident can just happen again.
So how do you ensure improvement? In order tolearn from incidents and to know what the cause isof an incident, you can use incident analysis. And another advantage of incident analysis is that it allows you to build a database on which to base improvement measures. With the ultimate goal of creating a safe(er) working environment in which incidents can, wherever possible, be prevented. But how do you decide which method suits you best?
Just google ‘incident analysis’. From the search results, it is difficult to determine what is objective information and what is commercially driven. However, if you were to lay the methods completely flat, they have two similarities:
Root Cause Analysis is often mentioned as a method. However, Root Cause Analysis is not directly a method but rather an umbrella term meaning almost the same thing as incident analysis. The methods like TRIPOD, PRISMA and SIRE, on the other hand, are toolboxes with capabilities to clarify the causes of incidents. Let’s zoom in on these methods.
As we mentioned above, TRIPOD, PRISMA and SIRE are commonly used methods to analyse incidents. For each method, we explain exactly how they work.
This incident analysis is often used to analyse incidents with a serious outcome. To prevent such serious incidents, it is important to determine the cause. This incident analysis is mainly used when analysing:
This method, which stands for Prevention Recovery Information System for Monitoring and Analysis, is used in healthcare. The aim is to analyse an incident in a structured way so that it can be prevented in the future.
Thanks to this method, root causes become clear. PRISMA also looks beyond human actions. Processes, the use of equipment and systems, management choices and organisational culture are also thoroughly analysed. Thus, everything that goes wrong in the healthcare process comes to the surface.
SIRE stands for Systematic Incident Reconstruction and Evaluation. This method is also used in healthcare. SIRE aims to improve the quality of care by identifying bottlenecks in care processes that may lead to incidents. This incident analysis method gives you insight into causes and consequences.
While searching for suitable methods, you will run into a jumble of terms. It will probably make your head spin when you read it all. What really distinguishes the methods from each other? And which one is best for your organisation? We understand these questions all too well, because there is a lot of overlap between the various methods. And that’s because they basically have the same goal, which is to investigate the root cause of an incident or series of incidents.
Broadly speaking, you can divide the various incident analysis methods into two categories. On the one hand, there are methods whose primary purpose is to analyse the analyse underlying causes of a single incident, or a limited subset of incidents. On the other hand, you will find methods that additionally aim to classify causes so that they can be included in a database. So to arrive at the right choice for incident analysis, it is good to consider which of these two goals you have in mind.
The most commonly used methods are:
Other methods may or may not be derivatives of these methods, or they are tools that methods work with. Unfortunately, it is not always clear what is now a method and what is a tool you can use within methods. Other tools include Fishbone, Event Tree and Timeline. The name is mainly derived from what the tool looks like when you plot the incident. Tools like BowTie are more tech-focused, where hard facts can be indicated. An Event Tree or Timeline offers more space for storytelling, where, for example, you look more at the soft conditions. However you put down the incidents and causes, ultimately the goal is to find out the Root Cause.
Above all, don’t stare blindly at the methods or tools, but choose one. The most important thing is that you use the method consistently so that the structure of the analysis is always the same. Especially if you want to classify causes to build a database, it is important that the outcome is uniform. Also, for everyone who has to deal with analyses (making, performing or receiving them), it is pleasant if a uniform method is used.
If you already use incident management software, or will do so, check immediately which methods and tools are supported. The ultimate goal is to produce good analyses. The methods and tools used are of secondary importance. After you have determined the main goal, plus found a pleasant tool, it is time to finally choose which method (or methods) you are going to use.
Many large organisations are already using incident analysis. Of course, you can go all the way to delving into all the pros and cons yourself, but you can also look at what others in your industry are already doing. For example, we see that in healthcare, SIRE is mainly used for serious incidents, where a one-time analysis is sufficient. PRISMA is also used, especially if one wants to build a database and thus classify the analyses. Within industry, TRIPOD (beta) is a commonly used method, often in combination with 5 Why (which was developed by Toyota) and/or BowTie.
Where work is done with strict rules, think of the food industry or a hospital, you can work perfectly well with tools that allow systematic and technical analysis. Hard facts can often be put down here without any problems. If you look at elderly care, for instance, such a method is often too hard. Here, it is often the ‘soft’ facts and a spider’s web of events that lead to a particular incident. A narrative analysis, with an event tree or timeline, for instance, works much better here.
For a long time, there has been the idea that security means the absence of insecurity. But a new current is emerging that assumes that people fail at some point anyway. Incidents can never be completely prevented or ruled out. However, by making analyses, improvement measures can be taken.
And that’s where Safety II urges to also look at what did go well during the analysis. What protocols and precautions, for instance, prevented a more serious incident? This positive approach can make improvement measures even more effective.
So get to work on incident analysis, then don’t forget to include the things that are going well in addition to the causes of failure. You can include this in any method, although a fishbone or timeline is a better representation for this than the BowTie. If you also want to include positives in your analysis, it is good to include this directly into the model.
Hopefully we managed to get you started with our tips. Download the infographic below so you always have them at hand.
The right incident management software gives you tools to streamline incident management within your organisation. Zenya allows you to both identify and classify the causes of risks. You can also link control measures to address the causes of risks. Want to know more about how to achieve the right incident analysis and how Zenya helps you do this? Our experts are ready to brainstorm with you about incident analysis options.
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