Don't Blame Staff When You Provide Them With a System With Failure Built in (HSG48)

One of the things that boils my blood is when staff are blamed for something going wrong, when the failure is systematic.

What I mean by that is that the system they are provided with is at fault and/or staff are being given legally incorrect advice and instruction.

The commonly held belief that incidents and accidents are simply and solely the result of 'human error' by the worker themselves is not necessarily true in all cases.

Blaming staff for the accident or error has for many years been 'convenient' for many organisations and also many training providers.

Why? - Simply because they can provide unsafe systems of work or inadequate training and then just blame any failure on the individual member of staff, with statements such as: "If you had applied the technique properly it would have worked".

Latent failures are made by people whose tasks are removed in time and space from operational activities, as opposed to 'active failures' that are usually made by front line staff.

Examples of the types of people involved in latent failures, therefore, could be: trainers, decision makers and managers and typically involve failures in health and safety management systems (design, implementation, monitoring and supervision).

In terms of physical intervention, an 'active failure' could be a member of staff who failed to implement a technique properly, which resulted in a service user or another member of staff being injured or killed.

But what we are finding now, is that the technique or system of intervention was going to fail anyway.

This is primarily because the technique had a high degree of failure built in and was therefore highly unlikely to work in such situations where it is required.

Add to that that:

1. The staff were poorly trained;

2. Given incorrect information and instruction; and

3. The company policy is legally flawed;

4. Creates uncertainty in what the staff can or cannot do when using physical intervention.

These latent failures can result in staff operating from a position of fear and anxiety, as opposed to being operationally competent.

This in turn increase the margin for error by creating an opportunity for an active failure to occur.

According to HSG 48: "Latent failures provide as great, if not a greater, potential for danger to health and safety as active failures.

Latent failures are usually hidden within an organisation until they are triggered by an event likely to have serious consequences".

In virtually every case, if a proper investigation is carried out, these latent failures are uncovered, which will probably admonish the individual of any blame for the error and place the failing at the feet of the organisational management systems that have contributed to the failure.

In designing our courses, we have looked deeply into our responsibility in preparing individuals for what they are being trained to do.

We have looked at the foreseeable human errors that could occur as a result of latent failings and then either eliminated them or reduced the likelihood of them occurring, which is what good health and safety risk management requires.

So, if you'd like to become a trainer in a competent, legally defensible and risk assessed system of restraint check out the webpage here - https://nfps.info/physical-intervention-trainer-course/

Eric Baskind and Myself Discussing The Legal Implications of a Care Quality Commission Freedom of Information Response

Mark Dawes' PodcastsBy Mark DawesMay 31, 2020