TRANSPARENCY Employee Near Miss Preventable Fatality DEATH INVESTIGATION Corrective ACTION Training Retraining Project MANAGEMENT Problem SAFETY accident engineering investigations bias BIASED reporting NONCONFORMANCE NCR corrective action LEADING lagging process indicators CONTINUOUS IMPROVEMENT METRICS ISO-14001 ISO-9001 OHSAS-18001 OSHA 200 Log Recordable Injury NQA-1 EPA ASQ E4 10 CFR 830.120 BMP Root Cause and Effect ANALYSIS Charting mapping QC Checklist systemic PMBOK Risk Management preventing RECURRING ADVERSE events Outcomes Patient HARM Trend Analysis PREVENT RECURRANCE reliability SYSTEM DOWNTIME Outages