First Aid Agency / Afterwards

Reviewing an incident without finding a culprit

The question is what made the good response hard.

A review that concludes somebody should have acted faster is accurate and useless. Everybody already knows that, and it produces defensiveness rather than change.

The productive questions are structural: was a trained person available, was the equipment where it should have been, did the person who found the casualty know what to do, and what made any of that harder than it should have been.

Those questions produce findings that can be fixed by a decision, which is the point of the exercise. Findings about individual performance rarely can.

The review should be quick, because memory of specifics fades within days and the people involved disperse. A short conversation within the week beats a formal report a month later.

Where the review identifies a change, it is worth telling everybody what changed and why. An organisation that visibly improves after an incident builds confidence that the next one will also be responded to.

There is a further review question worth asking, which is whether anybody hesitated to act because of a rule. Organisations sometimes have policies that discourage intervention, and a policy that produced hesitation in a real incident is one that needs revisiting immediately.