By Gary Evans, Medical Writer

When it comes to accident investigation, appearances can be deceiving.

A physician was injured after slipping on a wet hospital floor, but the clues to the cause led away from the site of the accident. A root cause analysis revealed that the chain of events that led to the injury began six months prior, when a maintenance contract lapsed on a dishwasher that was several floors above the accident site.

In addition to treating and reporting injuries, employee health professionals can be instrumental in accident investigations, says Stephen A. Burt, BS, MFA, president and CEO of Healthcare Compliance Resources, an affiliate of Woods Rogers Consulting in Roanoke, VA.

Hospital Employee Health caught up with Burt before he conducted a workshop on accident investigation training at the Sept. 5-8 conference of the Association of Occupational Health Professionals in Healthcare (AOHP) in Glendale, AZ.

“The whole idea of an accident investigation is really to prevent future occurrences,” he says. “I teach root cause analysis, where you try to find the one thing that if changed, eliminated, or minimized, the accident would not have happened. There may be two causes sometimes, but most of the time you can really narrow it down to one.”

The major causes of accidents and injuries in healthcare include overexertion, repetitive stress, patient handling, needlesticks, and slips, trips, and falls.

“It is the whole spectrum,” he says. “Anytime you have a report of an employee getting hurt, usually employee health gets involved. Often, it is on the back side when an [injured] employee comes to the clinic. But in many facilities, they go out, take a look, and try to see how it could have possibly been avoided.”

While violence in healthcare is an increasing concern, its unpredictable nature does not generally lend these incidents to the root-cause analysis approach for accidents, Burt explains.

OSHA defines a root cause analysis as a search for the “fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system failures.”1 Likewise, The Joint Commission issued a framework for root cause analysis that emphasizes a similar approach.2

“The problem with using a systematic approach for workplace violence is the human nature of the incident,” Burt explains. “People who initiate or who are causative factors in workplace violence are usually unpredictable.”

Root cause analysis certainly can help define possible scenarios and reasons why someone is potentially violent, but “I think we would be hard-pressed to use the root cause methodology to predict behavior or actions,” he says.

What should be predictable is that failure to maintain equipment could eventually result in a malfunction that causes an accident. In the aforementioned case of the physician fall, the source of the water that made the floor hazardous was not immediately apparent.

“There was water on the floor, but there were no carts, no housekeeping staff on the floor,” Burt says. “We noticed that the ceiling was leaking — a ceiling tile was dripping.”

Upon removing the tiles, a wet pipe was exposed, creating the initial appearance that it was leaking, says Burt, who investigated the case when he worked in a Virginia hospital.

“The water was not coming from the pipe, but running ‘along’ the pipe. So, we traced the pipe all the way back to the wall.”

Again, the water was coming from several floors above from a leaking dishwasher.

“We found that the root cause of the whole thing was that the purchasing department hadn’t notified dietary that the contract for the preventive maintenance had lapsed,” he says. “No one was coming to inspect and check the machine.”

A Framework for Investigations

In general, accident investigation in healthcare should follow these six steps, Burt recommends:

• notification and response;

• site investigation and interviews;

• root cause analysis;

• report of findings and review;

• implement corrective measures;

• ongoing monitoring.

“That gives people a framework of what to do when you are notified,” he says.

In the site investigation phase, photos are often taken, but Burt also favors a less conventional approach.

“Something that has always helped me is to take out a piece of paper and draw it,” he says. “Sometimes your eye and hand see things that the camera doesn’t. It is a little different approach to accident scene investigation.”

The investigation eventually leads to a decision point regarding interventions needed to prevent a recurrence; for example, better communication between the purchasing and dietary departments. The corrective measures must balance protecting employees with the real-world issues of healthcare cost containment. Sometimes major changes are warranted, such as if a floor cleaning product used hospitalwide is linked to multiple slips and falls, he says.

“It is a matter of looking at all the variables and doing a cost-benefit analysis in making decisions,” Burt says. “We do have cost constraints in healthcare. You have to figure out what is best for the situation and how to maximize the dollars that you have to spend.”

After consulting with hospitals on proper respiratory equipment use in the wake of 9/11 and the anthrax attacks, Burt saw that occupational health departments could play a greater role in accident investigations.

“I wanted employee health to be more involved,” he says. “Not just looking at the employee that was hurt, but the how, the why, and questions about the physical environment.”

For example, Burt noted some of the questions that arise after an employee is stuck by a needle in hospital laundry.

“How did it get there? Did a nurse leave it there?” Burt says. “Was it dropped out of a trash bag or a sharps container? There are a lot of things going on there that employee health can help with. Seeing the injured employee is, of course, important, but the investigative side can help get to those root causes and eliminate future accidents.”

Homegrown Safety

Employee health professionals facing a demanding list of responsibilities may see little time in their schedule to take on safety duties, particularly as they extend to outlying units and affiliated clinics and facilities. In a presentation also planned for the AOHP meeting, an occupational health leader says one answer is a “homegrown” safety approach that trains and empowers volunteers with diverse healthcare backgrounds.

These employees may have regular jobs ranging from nursing, engineering, or hospital security, says Cory Worden, MS, CSHM, CSP, CHSP, ARM, REM, CESCO, an employee health and safety officer at Memorial Hermann Health System in Houston.

The result is a web of safety knowledge that improves an organization’s safe culture through ownership and accountability.

“A lot of healthcare systems have patient safety, quality, and infection prevention at each of their campuses,” he says. “Those programs are very macro and run from the top of the organization down. With employee safety, most organizations either don’t have an employee safety manager or that person does double duty with risk management or occupational health.”

With leadership in employee safety falling to him and one colleague, Worden sought ways to extend the reach of the program.

“While we can’t have managers at each of the campuses, we still need to have safety expertise there,” he says.

Personnel who volunteer for safety in these other units are provided with training on the basics as well as the key regulations and recommendations by OSHA and the National Institute for Occupational Safety and Health (NIOSH), respectively, he says.

“We created a resource that contains information about the safety program, how to set up a committee, sample agendas, templates for minutes, and all kinds of training items to do a hazard analysis,” Worden explains.

A Sharepoint portal available to employees also includes documents that can be used as handouts, posted on bulletin boards, or sent out as emails.

“These are materials to get out to employees on a consistent basis,” Worden says. “It also provides resources for them when they do safety fairs or different events.”

The tools include observation checklists so data can be gathered on specific practices.

“We may find in 10 observations of patient-handling that in five of them the employees were not using the right equipment,” he says. “These are leading indicators on whether we are working safely or are at risk of an injury.”

Those who volunteer for these duties are offered professional development and paths to safety certification by national organizations.

“Professional development increases their skill level, confidence, and morale,” Worden says. “It shows they are a leader in employee safety, and that role is taken seriously.”

Training programs also are conducted through an affiliation with Texas A&M University in College Station.

“Our leaders go through courses that cover different safety areas, including safe patient handling, communication, and bloodborne pathogen exposure prevention,” he says.

In addition to training and certification, some of the safety volunteers are nominated for awards and honors by the various national associations.

“These volunteers are taking this on and doing it with the same vigilance as a professional,” Worden says. “We always make sure we set them up for success and show that we appreciate them.”

The program is yielding positive results, dropping in three years from an injury rate of 4.74 per 100 employees to 2.78 injuries per 100 workers.

Work Culture Perceptions

Those are tangible results, but there is some evidence that just the perception of a safety-conscious culture can result in fewer accidents and injuries. Researchers are exploring this connection in some preliminary data from an unpublished study, says Aaron Spaulding, PhD, of the Mayo Clinic in Jacksonville, FL.

In a study of 1,800 employees working in a large tertiary hospital in the Midwest, Spaulding analyzed occupational injuries and safety climate perceptions by employees.

The perception of a responsibility to comply with safety rules within the unit by healthcare workers was associated with fewer injuries, he said. It follows that policies and feedback that reinforce the safety culture will better protect healthcare workers.

“If they believed that their peers and supervisors were doing the right thing in terms of safety, they had fewer injuries,” he says. “As we looked at the overall number of injuries occurring on a work unit, the more highly they scored their supervisors and peers on safety, the less likely they were to get injured.”

In contrast, workers that viewed the safety culture as lax were less likely to comply with protective measures to prevent injuries and accidents. From the employee standpoint, this could include seeing that safety issues are going unaddressed, protocols are not followed, and malfunctioning equipment remains unrepaired.

“They may think maybe [safety] isn’t that important — nobody else cares,” he says. “From a peer perspective, if everybody around me is not doing these activities, then why should I?”

There may be issues with safety in terms of what is communicated to workers on the floor by facility leadership, he adds.

“From a general employee perspective, the supervisor tends to be the voice of the organization,” he says. “If management and leadership are really supporting a safety culture, that tends to go a long way in terms of shared values and beliefs [of workers].”

The study found that workers in direct patient care were more likely to incur injury, but were less likely to miss work, he says.

“That was somewhat surprising,” he says. “They were at greater risk as direct patient care employees, but workers in nonpatient care were more likely to experience absent days.”

Possible explanations include that patient care workers feel a responsibility to be at work for their patients and colleagues, he notes. While these preliminary findings were to be discussed at AOHP, a more detailed analysis will be forthcoming when the research is published, he says.


1. OSHA and EPA. Fact Sheet: The Importance of Root Cause Analysis During Incident Investigation. October 2016. Available at:

2. The Joint Commission. Framework for Conducting a Root Cause Analysis and Action Plan. Oct. 11, 2017. Available at: