Types of Events

Types of Events

In our everyday lives, accidents or error-based events are set apart from one another depending on their outcomes. Consider the following:

It's a rainy evening at rush hour. As you hurry to catch a plane, you turn on your lights and wipers to see more clearly. Road work ahead forces you to take an unfamiliar detour.

You are somewhat distracted as you attempt to check the flight information in your date book and go over the list of to-dos. Your new supervisor comes to mind-the guy who's trying to prove himself by over-committing your team and then pressuring you into attending tomorrow's 8 a.m. meeting at the client site.

You approach a busy intersection. However, tree limbs, weighed down with the rain, are hanging across the road in front of the traffic light.

As you reach the intersection, an event will occur. But this same circumstance could have three different outcomes.

Compare the three possible outcomes as unique types of events.

Misadventure

Outcome 1 – You don't see the light in time to stop. You hit a car broad side.

In this event, you ran a red light, hit a car crossing the intersection, and caused a major wreck. This could be categorized as a misadventure.

A failure occurred, there was no recovery, and the outcome produced some level of injury.

No Harm Event

Outcome 2 – You don't see the light in time to stop. Although the light is red, no cross-traffic vehicle is in the intersection at that moment so there is no collision.

In this instance, you ran a red light but by sheer good luck you did not cause an accident. This may be categorized as a no harm event.

A failure occurred and there was no recovery, but luckily, no harm was done.

Near Miss Event

Outcome 3 – You look up just in time to see the light turning red. Reacting fast, you slam on your brakes and screech to a halt.

By applying the brakes at the last minute, you stopped at the light and avoided an accident. This event may be categorized as a near miss.

A failure was averted. The recovery action was applying the brakes just in time.

If the recovery action of a near miss event is planned, then the potential consequences were prevented by some sort of barrier.

A barrier is any action of process built into the work flow to check for accuracy or quality and that may prevent an incident.

Example:

On completing a quality control check list prior to the start of the shift, the tech notices that an expired reagent was placed into use for that day's testing.

However, although barriers are designed to avert accidents (or facilitate recovery), recovery does not always occur as the result of a barrier. Unplanned recoveries happen by chance.

Consider the following examples:

A driver and passenger approach a washed out road.

Example 1 – There is a flashing road block. The driver sees it and avoids the danger.
The roadblock is the barrier that facilitates a planned recovery.

Example 2 – There is no roadblock, but an observant passenger sees the washed out road and yells, "Look out!"

The driver's response is the same, but this time it is an unplanned recovery.