Table 3 Fifteen requirements for effective safety feedback for incident reporting and rationale as to how each has a positive impact upon operational safety
01Feedback at multiple levels of the organisationFeedback or control loops should operate at multiple levels of the organisation across individual teams, units or subdepartments. They should also operate across organisations. This allows lessons learnt in one particular context to be applied as broadly as possible in as many similar localities as possible. A single organisation might experience a rare incident, but all organisations can learn from it.
02Appropriateness of mode of delivery or channel for feedbackFeedback should utilise a variety of modes, formats or channels to increase the awareness of as wide an audience as possible. Email bulletins, workplace leaflets, bulleting board postings, team briefings or safety newsletter publications can all be used to provide staff feedback.
03Relevance of content to local work place and systemsThe content of safety information fed back should be targeted to individual work system contexts so that operators receive only what is necessary and relevant to their operations. Feedback should be suitable and meaningful within the local context, with high-level guidelines and policy being directly translatable into specific actions and behaviour on the local level.
04Integration of feedback within the design of safety information systemsThe capability for useful feedback functions should be embedded within the design of risk-management IT systems and incident databases, in addition to reporting and analysis functions, so that the reporting community can access or generate customised reports to support local quality-improvement activities.
05Control of feedback and sensitivity to information requirements of different user groupsCareful consideration needs to be given to how information, especially concerning safety incidents, will be presented to specific audiences, particularly the public and external audiences.
06Empowering front-line staff to take responsibility for improving safety in local work systemsEffective feedback should support front-line staff, while illustrating how they can take responsibility for improving operational safety in their local working environment. Channels, mechanisms and forums should be provided to create dialogue and through which front-line staff can respond to feedback.
07Capability for rapid feedback cycles and immediate comprehension of risksThe feedback loop, or a rapid response process, should complete quickly for immediate threats to safety, even if only to offer temporary solutions/workarounds or raise the profile of an issue in staff’s awareness until a more detailed investigative process can be completed. Communication of an “unsolvable” safety issue to the reporting community can often prompt further reports and suggestions for solutions.
08Direct feedback to reporters and key issue stakeholdersFeedback should be provided to individual reporters and other stakeholders at varying stages of the reporting loop. Feedback and dialogue with the original reporters is important immediately following an incident and when actions are taken. This fosters a reporting culture as people can see their report has been acted upon.
09Feedback processes are established, continuous, clearly defined and commonly understoodClear definition of process steps, roles and responsible organisational bodies ensures that the safety improvement process is accepted, commonly understood and proactive, in contrast to temporary investigative structures that are convened to identify problems in hindsight, following a serious incident.
10Integration of safety feedback within working routines of front-line staffBecoming aware of up-to-date safety information is a formal requirement of the work role, and feedback is designed to be minimally disruptive to productive work tasks. Behaviours such as checking safety bulletin boards are incorporated into routine daily practices, and time is allocated for safety awareness activities. Recent, relevant incidents are discussed at quality reviews and pretask briefings.
11Improvements made within local work systems are visibleIt is necessary to demonstrate the impact of reporting on improving local work systems to encourage future reporting to the system. This allows busy professionals to justify the efforts they make in reporting their errors, near misses and incidents, and challenges the view that reports disappear into a “black hole.”
12Front-line personnel consider the source and content of feedback to be credibleFront-line staff must trust in the commitment of other areas of the organisation and its leadership to the goal of operational safety, if they are to accept the organisational changes and safety initiatives that are fed back.
13Feedback preserves confidentiality and fosters trust between reporters and policy developersReporters do not expect any negative personal consequences from reporting. There are clear policies and guidelines concerning an appropriate level of confidentiality and de-identification built into the reporting and analysis system. Information is not personally identifiable, while preserving sufficient references to the original work systems to be useful.
14Visible senior-level support for systems improvement and safety initiativesSafety actions are visibly sponsored and supported at a senior level of the organisation. Safety actions fed back to the local level are followed up and management visibly drives this process. Leadership of safety issues reinforces the emphasis placed upon commitment to shared responsibility for high standards of operational safety alongside other productivity goals.
15Double-loop learning to improve the effectiveness of the organisation’s safety-feedback processThe safety-improvement process or control loop is itself subject to monitoring and evaluation in order that the system may be developed to better detect and mitigate vulnerabilities.