Determining What to Report
There is a difference between an incident and an accident. At Middleton-Cross Plains Area School District (MCPASD), an incident is considered a “wake-up call.” It is an event that has the potential for injury, harm or damage to a person or property. Whereas an accident is an event that actually injures, harms or damages a person or property and impacts insurance premiums.
As it turns out, a large majority of safety events that occur at MCPASD are only incidents. Since every incident has the potential to turn into a future accident if not addressed appropriately, MCPASD airs on the side of caution and reports all incidents and accidents so they can address all issues to reduce the chance of future human injuries. If the district neglects to address every event, it is opening itself up to greater liability. By reporting and addressing all events, the district is doing its due diligence to keep students, staff and the public safe while protecting itself from lawsuits and rising insurance costs.
Adhering to the Process
Once an incident or accident happens, how a district reacts to it is directly related to the impact the event will have on the district overall. When the reporting, investigation, and addressing of hazards and other accident management processes are addressed quickly and thoroughly, the district reduces its risk. Regardless of whether an event is an incident or an accident; MCPASD follows the same six steps, which were developed by the district’s former assistant superintendent of business services and managed by an automated software program.
1. Notification. The first step is to immediately report the event. The online software’s automated reporting system alleviates the issues the district was having with a paper-based reporting process, such as not knowing if a report is completed, losing days as paperwork traveled to the appropriate interventionist, delayed investigations and unreliable communication with the insurance carrier. Moving to the online reporting and tracking systems helped the district work more effectively and compassionately with all parties, and timely reporting of accidents has improved the district’s insurance premiums. Employees return to work and to a normal life more quickly because information is immediately available to supervisors and administration to allow immediate follow-up as well as rapid implementation of the district’s return-to-work program. It also solved the district’s issue of being short staffed or reliant on costly substitutes when someone was out due to an accident.
Now, when a student or staff member is injured, a staff member completes and submits an online incident or accident report. The online report form requires that all vital fields are completed properly. Once submitted, key site and district staff members are automatically notified to take appropriate steps based on their role in that process. This includes, but is not limited to key administrators, supervisors, the school nurse, the principal, a student’s parents (if applicable) and the district’s insurance carrier(if applicable). So now, the district’s ability to report an accident to all appropriate parties has reduced from up to a week to seconds.
2. Response. What happens when an incident or accident is reported is just as important as the reporting itself. When an incident or accident occurs, the necessary medical treatment needs to be administered (if applicable). Timely reaction to address and contain hazards such as roping off the area helps avoid additional injuries.
3. Fact-finding. Fact-finding, or the collection of evidence and information for the investigation, should take place immediately following the incident or accident. This may include, but is not limited to, taking photographs and/or video of the scene, documenting the sequence of events and interviewing involved employees and other witnesses. Once evidence is collected, the district uploads it to the online accident report. Since all of this information is centrally located, all appropriate parties can access the report to add details to the log throughout the investigation process.
4. Analysis. Analyzing the “what” and “why” behind an incident or accident is the first step to creating a prevention plan. The “what” is called the surface cause. It is the unsafe conditions and behaviors that directly caused or contributed to the event. The “why” is the root cause. It is the underlying weaknesses that contributed to the surface cause. There are two types of root causes: system design weakness or system implementation weakness. A system design weakness is when policy or procedure (like training or safety plans) are missing. A system implementation weakness is when policies and procedures are in place, but employees and students are failing to adhere to them.
For example, a student falls on the playground and injures his arm. After speaking with the student and his friends who witnessed the accident during the fact-finding stage, the administrator found that the student tried to flip off of the swing backwards and fell landing on his arm. The student’s misuse of the swings is the surface cause. The root cause would be why he was misusing the swings. If he was unaware that it was unsafe because the school did not have a rule about proper swing use in place, this would be a system design weakness. If there was a rule in place, but the student chose to ignore it, this would be a system implementation weakness.
With most accidents, there may be more than one surface or root cause in play. For example, let’s say the playground uses loose-fill surface materials such as mulch or sand to fill the playground areas. Schools are responsible for making sure that the playground surface materials are a certain depth to ensure students are protected if they fall. Areas under swings and slides are more susceptible to displacement and compression, so they should be maintained more frequently. During the fact-finding stage, the administrator measured the depth of the playground surface materials under the swings and found it was both too compressed and not deep enough. These would be additional surface causes. If the school did not have a process for monitoring the depth of the playground surface materials on a regular basis, this would be a system design weakness. If there was a procedure in place, but an employee forgot to complete this task, this would be a system implementation weakness.
5. Corrective action. Once the root cause(s) has been determined, the next step is planning and implementing corrective action. If there were multiple surface or root causes, there must be multiple corrective actions. In the previous example, there were two surface causes: the student was misusing the swings and the playground surface material was not deep enough.
To address the surface cause regarding how the swings are used, if the school did not have rules in place, they should be created, communicated and enforced. If these rules were in place, but were not enforced, the school may require direct enforcement of the rules to students. To address the surface cause regarding the playground surface materials, first—the materials should be replenished so they are the appropriate depth. If there was not a process for monitoring the depth on a regular basis, the district must create one and enforce it. If there was a process in place, but the surface materials were still too compressed, the school may need to measure the depth more frequently, especially in high traffic areas.
After identifying the corrective actions, identify who will be responsible for implementing them. For example, in MCPASD’s case it may be necessary for one of the educators on recess duty to stand by the swings to ensure students are using them correctly. As for checking the depth of the playground surface materials, the maintenance crew will implement a periodic preventative maintenance routine to ensure measurement and replenishment are completed as necessary. Once the corrective action is determined, those parties responsible for completing them must be notified of their role and of the expected timeline for completing the actions. With a comprehensive online system, all of these communications can be automated, thus ensuring each is taking place in a timely fashion.
6. Follow-up. The follow-up stage consists of several parts. First, make sure the responsible parties are completing their corrective actions on time. For instance, if a safety administrator opens the online work order requesting that the playground surface materials be replenished and he or she finds that it has not been completed in a timely fashion, he or she can step in and contact the maintenance department to ensure it gets completed immediately.
Part of follow-up includes evaluating the corrective action to ensure it was effective in preventing similar incidents and accidents. When all accident reports are stored online in a comprehensive system, it is easy to pull trends reports to see if incidents or accidents are continuing to occur or if preventative measures are working.
A Learning Opportunity
By reducing the time it takes to report and investigate events, address hazards, implement preventative programs and communicate with insurance carriers, organizations can reduce insurance premiums and ensure that employees, students and visitors are spending their days in a safe environment. Whether an organization is ramping up safety training, tweaking a process or even completely revamping the accident management process, it is the perfect opportunity to learn from mistakes and implement a truly preventative program.