Use close-call investigation questions that identify root causes and control gaps.
Close call A lab cart rolls out of a storage room and nearly hits a visitor in the hallway. The intern says it was their fault for not looking. The last action is visible. The control gaps are not. Near-miss investigation Facts -> Conditions -> Controls Start with what happened, then ask what conditions made it possible, then choose controls that prevent the same pathway. Blame Tell the intern to be careful. The same close call becomes less likely for everyone. A good investigation asks why the error mattered and what would make it harder to repeat. 01 Facts 02…
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