Potentially fatal incidents: identification, classification and human factor analysis

J. Lezdkalne*

University of Latvia, Aspazijas blvd. 5, LV-1050 Ria, Latvia
*Correspondence: jelena.lezd@inbox.lv

Abstract:

Potentially fatal incidents (PFIs) are increasingly used as leading indicators in high-risk industries, yet their definitions, classification criteria, and investigative depth vary widely across organisations, limiting. their preventive value and comparability. Human factors (HF) play a critical role in determining whether incidents escalate into PFIs and must be considered together with technical and organisational barrier performance. This research aims to examine the role of human and organisational factors in PFI identification, analyse misclassification patterns, and propose a human-factors-based model to improve PFI classification consistency and learning value. A retrospective document analysis was conducted using incident reports from a heavy-industry organisation covering the period from 2020 to 2024. The dataset was systematically reviewed and PFI classifications were re-evaluated using a structured framework integrating hazardous energy and exposure assessment, barrier performance evaluation based on Bow-Tie logic, and human and organisational factor coding using an HFACS-based structure. Analysis revealed inconsistency in PFI classification, including overclassification and under-classification linked to limited recognition of human and organisational factors. Number of incidents were labelled as PFIs despite lacking credible fatal energy exposure, while other events with systemic and human-factor contributors associated with fatal risk were not recognised as PFIs. The HF-PFI Model demonstrated improved classification reliability by integrating energy exposure, barrier status, human factor categories, and systemic indicators. Integrating human-factors analysis into PFI identification can strengthen serious injury and fatality prevention in high-risk industrial environments.

Key words:

Predictors of safe behaviour and holistic framework for promoting proactive safety culture in healthcare and nursing homes

J. Sepp

Tallinn Health Care College, Academic and International Affairs Office, Kännu 67, EE13418 Tallinn, Estonia
Correspondence: jaana.sepp@ttk.ee

Abstract:

The poor safety culture in nursing homes is attributed to the lack of professional and safety competencies, management commitment, and limited empirical data. The purpose of this study is to identify potential predictors of safe behaviour among care workers and establish a holistic framework for a proactive safety culture in healthcare and nursing homes. The study was conducted in 25 care institutions between September 2014 to December 2017 using mixed-methods with quantitative (NOSACQ-50; CCQ, COPSOQ II) and qualitative (focus-group interview) components. Results revealed challenges with safety systems and management, lack of resources and time, and the importance of leadership and psychosocial well-being. The study identified subcultures of proactive safety culture, including professional competence culture and psychosocial well-being culture. These subcultures aid in identifying weaknesses and improving quality, emphasizing the need for a holistic approach to safety culture in healthcare institutions, particularly in nursing homes. The author’s proposition on positive safety culture, based on the theory of situated cognition, highlights the significance of subcultures such as professional competence culture and psychosocial well-being culture in influencing care workers’ professional identity and safety behaviour. In conclusion, the importance of these subcultures can be emphasised due to ensuring adequate understanding and positive attitudes towards safety. Adequate care worker training and a culture that supports professional competence are crucial for patient safety and organizational outcomes. Addressing psychosocial risks and promoting a culture of psychosocial well-being can create a safer workplace culture and improve employee performance, job satisfaction, and overall organizational outcomes.

Key words:

nursing homes, professional competence culture, psychosocial well-being culture, safety climate, safety culture, safety management.