Metaanalys av förslag på åtgärder i kommunala olycksundersökningar

Sammanfattning: This paper carry out a qualitative meta-analysis of 112 “proposals for action” identified in 30 of the approximately 630 accident investigations that are published on the Swedish Civil Contingencies Agency (MSB) website. Accident investigations have been carried out at the discretion of each municipality and then sent to the MSB, which in turn, after a secrecy review and an ethical review, publishes most of the investigations on the web page Kommunala olycksundersökningar. The accident investigations are split into a number of different categories by type of event and the categories analysed in this paper are “Automatic alarm - not fire” and “Fire - not in building”.The process of learning from accidents can be illustrated using the CHAIN model (Reporting - selection - Investigation - spread - implementation). This model attempts to show how the process of learning from accidents step by step and point out that every step must be followed and implemented for a lesson to be learned - from event to implemented lesson learned. Previous studies however have found that the steps in the CHAIN model are not followed from the beginning to the end in terms of learning from municipal accident investigations. A first problem is that some proposals listed can be unclearly formulated in terms of who is supposed to carry out the proposal, but above all, there are weaknesses in distribution and thus also the implementation of the proposals.Aim and method This paper seeks to compile, analyse and present the proposals for action contained in the selected accident investigations. The method used is a qualitative meta-analysis understood here as an "analysis of analyses" performed with the qualitative method content analysis, which may also contain quantitative elements.Findings Almost all of the proposals set out are alone in its kind. There is just two proposals contained more than once. Proposals for measures can be further divided into categories by thought, or stated, receivers and for similarities between the proposals. More than half of all proposals are targeted to Rescue services own work, either regarding the intervention itself, organizational or other planning or collaboration with other agencies or stakeholders. One group is aimed towards the operator and propose improvements in various parts of their systematic fire prevention (SBA). Two smaller groups of proposals suggests improvements for handling errors and to do changes in the products and that this information should be communicated to operators/retailers or producer. Some proposals do not fall within any of the other categories.It noted that, in principle, all suggestions are workable and implementable and that these proposals can be generalized beyond its original context into a larger one. And that this kind of qualitative meta-analysis can be a part of the CHAIN model's implementation.