In an effort to bring attention to a significant risk that demands our awareness: the tragic instances when young children are unintentionally left alone in sweltering vehicles, leading to fatal consequences. Startling statistics KidsandCars.org, reveal that, between 1990 and 2020, an average of 39 children lose their lives each year in the United States due to hot car incidents. In fact, 2018 and 2019, were the worst years with 54 and 53 reported deaths, respectively. The number of deaths went down in 2020 to 25 fatalities, but this is likely attributed to COVID-19-related restrictions, closed childcare facilities and reduced travel.
As we move into the summer months, it’s important that we understand how and why parents and caregivers too often forget children in the backseat so we can prevent it from occurring in the future. In this blog, we delve into the crucial subject of preventing these unimaginable tragedies. Using Cause Mapping® root cause analysis we shed light on the pivotal role human error plays in these devastating events and emphasize the necessity of addressing this factor to effectively mitigate the associated risks.
In fact, one of the first errors that a caregiver can make is to ignore the risk due to the false perception that this could “never happen to me.” Psychologists refer to this as optimism bias, and, unfortunately, it causes us to underestimate risk. A critical risk that we must account for is that our memory is fallible, in spite of our best intentions and regardless of the severity of the outcome.
When we forget or lose focus during an important task, there are multiple causes that align to produce the outcome. Revealing this system of causes provides opportunities to control those causes and prevent occurrence. In fact, when analyzing problems that involve “human error,” it is common for investigators to focus solely on the human condition and summarize the incident as “inattention,” “complacency” or the self-evident “human error.” These generic explanations result in generic, ineffective solutions, such as “be more careful” or “pay more attention,” and in some cases, even disciplinary action.
In addition to revealing the causes related to human error, another important opportunity is to reveal causes that contribute to the consequence of the error. Mitigating the consequence of an error is an important feature of highly reliable organizations (HROs) and reveals opportunities to add layers of protection. For example, on the Cause Map diagram, there are three causes required for the child to be left inside the car: the child was left in the vehicle because the caregiver forgot to drop of the child at daycare AND they are unaware the child is still inside the car AND they are able to leave the car with the child still inside.
Identifying a solution that controls ANY ONE of those three causes prevents the fatality. For example, some vehicle manufacturers, including Hyundai and Ford, have begun including an automatic reminder in their new model vehicles to remind drivers to check the backseat. Or another creative solution is to change your process for driving, so you always place an item you wouldn’t get far without, like a shoe or your work badge, in your back seat with the child. This reveals significant leverage from a process reliability standpoint. We can significantly increase the reliability of the task in spite of human error.
Finally, even if you leave the child in the car, are there opportunities to incorporate backup reminders as another layer of protection? For example, if the childcare provider is expecting your child, instruct them to call immediately if the child doesn’t arrive on time. You can learn more about other potential solutions and further understand how to help prevent these incidents at kidsandcars.org.
If you are interested in learning more about how to analyze human error and incorporating concepts around Work Process Reliability into your problem-solving investigation, I would encourage you to attend the upcoming two-hour online short course. For more information and registration information visit us at training.thinkreliability.com/catalog.