November 21, 2018 | Mark Paradies

What is a Precursor Incident?

What is a Precursor Incident?

Perhaps the simplest answer is:

Minor incidents that could have been major accidents
if one or more Safeguards had failed.

Many times LUCK is the last Safeguard that has saved someone’s life. How about this:

Another 3 feet and the guy with his back turned would have been dead. Pure luck.

That Precursor Incident is easy to spot. But many Precursor Incidents are less obvious.

Spotting a Precursor Incident means spotting failed Safeguards or an unidentified Hazard/Energy before an accident happens. A failed Safeguard in a system with multiple Safeguards IS a Precursor Incident. Energy without an effective Safeguard IS a Precursor Incident.

Are you looking for Precursor Incidents? Are you investigating Precursor Incidents and finding and effectively fixing their real root causes?

Did you know that the TapRooT® folks have a book and a course all about investigating Precursor Incidents?

The book is:

Using the Essential TapRooT® Techniques to
Investigate Low-to-Medium Risk Incidents

The course is:

2-Day TapRooT® Root Cause Analysis Training

You can’t afford to wait for the causes of Precursor Incidents to come together to cause a major accident

Fix them whenever they provide a warning to avoid the devastation of a fatality, major fire, explosion, regulatory fine, or major customer complaint. Take a look at the type of TapRooT® Courses in light of your needs, then register your teams in upcoming TapRooT® Courses being held around the world. For questions, contact us via email or call us, at 865-539-2139.

Why TapRooT® Root Cause Analysis?

We have a team of investigators and instructors who have years of extensive training ready to offer assistance worldwide. We also offer ongoing support to our clients through free newsletters and root cause tip videos (TapRooT® TV), the Root Cause Analysis Blog, and our annual Global TapRooT® Summit. We’re here to find solutions for you.

Courses & Training, Operational Excellence, Root Cause Analysis, Root Cause Analysis Tips
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3 Replies to “What is a Precursor Incident?”

  • Sonya Cass says:

    I’ve had TapRoot training years ago as it applies to Healthcare. What would you recommend calling near-misses in the healthcare field? I currently work in a small to moderate clinic, and I don’t believe “Precursor Incident” would elicit the reporting that I would hope for. I hate the phrase “Good Catch”, but my supervisor wants a “more positive spin” on near miss reporting. Any suggestions?

  • Mark Paradies says:

    First, this article:

    might help you better understand the theory behind precursor incidents.

    Then you will have to decide what is a near-miss in your healthcare field. Sharing examples might help you communicate the idea to employees.

    This article:

    introduces the idea that a failed Safeguard is potentially a precursor incident (near-miss). That might also help explain the concept.

    Here is an article about the terminology of near-miss and precursor incident:

    In the healthcare industry I have seen near-misses called:

    – Close calls
    – Good catches
    – near-misses
    – precursor incidents

    I don’t know if any of these helps with putting a more positive spin on near-misses to get additional reporting.

    What I have seen help reporting is quick, effective fixes to improve the work and prevent future mistakes. Employees usually find this very positive.

    What prevents reporting of near-misses is blame. The first time someone is fired (even deservedly) over a near-miss, you will notice a marked decline in reporting.

    One more thing you may want to review is a Lancet article about healthcare near-misses:

    • Sonya Cass says:

      Thank you so very much Mark! I wish I recalled the name of my instructor for TapRoot, because he was awesome. This would have been around 2010 or so.
      Have a fantastic year!

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