Are your error investigations getting beyond the human?

Agree the terms of reference up front, provide us access to data and people; we will do the rest and present you with a detailed report identifying;

• A detailed sequence of events;
• Contributory or causal factors, including a breakdown of culture, process, organisational or individual factors;
• Root cause.

The investigation may present further opportunities to prevent a future event, so we shall also identify risks or areas for improvement.

Whether you are not able to assign 2 investigators, or you require a totally independent party to support the investigation, we are able to act in a lead or supporting role.

Being able to draw on people from outside the organisation not only limits the effect on business as usual activity, it can enable better outcomes that only come from those 'this may be a stupid question' type questions of a layman. 

A review group, totally independent of the investigators is a key component of a just, open and committed culture; having someone on that review group from outside your organisation, is the most significant demonstration of commitment to this. 

The benefits this brings include;

• Disruption of organisational culture, unconscious bias and personalities in the review group;
• Reduction in likelihood of assumptions or organisational norms distorting the facts;