HOP Incident Inquiry

Learning from Everyday Work

USING HOP PRINCIPLES

Next

Everyday Work

Incident

Event

How does this...

Become this?

Everyday Work

Start by learning about your Staff's Everyday Work

Ask questions like...

• Tell me about your work?
• What does a good work process look like?
• Where is it easy to make a mistake?
• What is predictable?
• What is unpredictable?
• What is the worst thing that can happen?
• What "workarounds" do you need to employ?
• What near-misses have happened?
• What else would you like me to know?

And then...

Remember...

If we spend time before an incident understanding the ins and outs of daily work, we'll be in a much better place to engage in meaningful sensemaking when an adverse event occurs.

We'll have a better understanding of

• How people’s decisions and actions (or inactions) made sense to them at the time.

• What people saw and experienced that led them to respond as they did.

• What surprised them about the situation they found themselves in.

• What made the situation difficult, hard to interpret, or complicated.

• What pressures they were feeling that contributed to the choices they made.

...and we'll be better equipped to anticipate, mitigate and learn from near-misses and incidents!

Event Sensemaking

Use your understanding of Everyday Work to explore the variables that may have led to the incident.

• What was different before or during the event?
• How far back do we need to go to understand?
• What did you hear/see/think at the time?
• What else should we know to make sense of the decision-making surrounding the event?

Event

How does understanding Everyday Work help us resist the temptation to find a "root cause" of an incident?

Show me!