Many near miss reporting (NMR) systems don’t work as intended. In most systems, what typically gets reported includes: (1) only events severe enough or with witnesses where there is no other option but report; and (2) “softball” near misses like paper cuts or a deer on the shoulder of the highway on the way to work.
Why this gap between near miss reporting systems’ intent and ultimate impact? Many NMR processes function to discourage the very behavior they require: reporting a situation where an injury or damage could have happened but didn’t. The systems inadvertently punish reporting substantive near misses.
Frontline employees will tell you that reporting a significant near miss leads to undesirable consequences for them. Rigorous investigations, with the best of intentions, can feel like an inquisition to the person sharing the critical information. Phone calls from executives, while intended to show support and management attention, can be very intimidating to the receiver. Publicized near miss bulletins can bring unwanted attention and embarrassment to the individual, team, unit, and area of a near miss. In the worst-case scenario, employees who report near misses are disciplined.
Even without punishing consequences, it’s important to realize the need to positively reinforce near miss reporting. Near miss reporting is voluntary. Voluntary activities require support by positive consequences. Unfortunately, reporting a near miss is not naturally positively reinforcing, so organizations must build reinforcement into their near-miss reporting processes. Without positive reinforcement, an employee faced with the decision between reporting and potentially being embarrassed, grilled, or even disciplined, or saying nothing and avoiding all negative consequences, will opt for keeping quiet. Many will conclude (as evidenced by their behavior) that it is much better to continue with the task at hand even when there was a close call or a learning opportunity that others could benefit from knowing.
Four positive steps
Here are four important ways to build positive reinforcement into your near miss reporting system:
1 Make immediate consequences positive: The first thing that happens to someone who reports a near miss is critical. The immediate consequence should make the employee glad they reported. Ease of reporting is an important part of this. When reporting systems are cumbersome, time-consuming, can only be done on a computer, etc., people are less likely to report because those immediate consequences discourage it.
What and when does the person reporting the near miss hear back about their report? If the first response they get is a phone call from an agitated boss, reporting will be discouraged. Near misses are bad news and don’t usually make management happy. Check your emotions and remember that your first priority is to reinforce the behavior of reporting.
2 Minimize the work: Another mistake often made is that reporting a near miss leads to more work. Reports are followed by a barrage of questions, repeated inquiries, multiple meetings and requests to review the incident. Most employees would like to report the near miss and get back to work. Obviously, near misses are most helpful when there are sufficient details, so some information gathering is inevitable. If possible, provide a single point of contact that gathers all the information required (ideally in one sitting). If more input is needed, provide support for the person who reported and minimize requests to repeat the same information.
3 Anonymity can jump start a process: Whether or not anyone has ever actually been disciplined for reporting a near miss, there is likely to be suspicion and fear that will deter people from finding out. By making a system anonymous initially you can demonstrate a positive and productive response to near misses so that over time people will be willing to share their name.
4 Let people know it mattered: The best reinforcer for reporting a near miss is to know it helped others avoid getting hurt, or improved safety in some way. The worst-case scenario is near miss reports that appear to go into the organizational black hole, never to be seen or heard about again. Word quickly spreads that there is no point in reporting near misses if people don’t see any evidence that the report made a difference. Set up your near miss reporting so that people can see the output from the system ideally within a day or so of reporting. Publicize corrective actions that were taken or policies that were revised based on knowledge gleaned by near miss reporting.
Be honest about errors
Near misses often provide feedback on management practices that set up frontline errors. A healthy near miss reporting system, in fact a healthy safety culture, starts with leaders honestly acknowledging their role in organizational errors at the frontline. It goes a long way toward improving the safety culture when leaders admit their mistakes and work to change them.
Blame is the enemy of near miss reporting, and indeed of productive safety cultures. Honestly and openly acknowledging that mistakes are made at all levels of the organization and demonstrating a commitment to reducing mistakes by taking action immediately is a hallmark of a good safety culture. Expecting frontline employees to publically admit mistakes but not expecting leaders to do the same undermines safety improvement.