Clinical Risk Unit
Research - Investigation Protocol

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Methods for investigating critical incidents in healthcare



Background

The aim of the project is two fold:-

The assessment of adverse medical outcomes has generally focused on identifying relevant patient and treatment characteristics. Most studies have taken the form of large scale audits of serious incidents. These questionnaire-based surveys have provided valuable data on the nature and frequency of adverse outcomes but limited information on their causes. Serious incidents are routinely discussed in mortality and morbidity meetings. However, discussion is usually limited to patient and treatment characteristics, and the identification of any clear cut departures from expected standards. There is seldom any attempt to identify the chain of events leading to an adverse outcome and the wide range of factors that influence clinical performance. In contrast, sophisticated methods of accident analysis have been developed in aviation, nuclear and chemical industries based on human factors approaches to safety. Human factors is a hybrid discipline which focuses on the human component within complex organisational systems. The assessment of what can go wrong with large scale systems such as Nuclear Power Plants and Transport systems has received considerable interest given accidents such as the Kings Cross Underground Fire, Three Mile Island and Chernobyl, where cause has been directly attributed to "human error". As a consequence of such disasters, these industries have developed a variety of methodologies to identify human errors within a system, to quantify the impact of human error on the system and finally to provide measures for error reduction. We have based our work on Reason's Organisational Accident Causation Model [1,2,3]. This method essentially examines the chain of events that lead to an accident or adverse outcome, considers the actions of those involved and then crucially looks into the conditions in which staff were working and the organisational context in which the incident occurred.

The CRU's research has focused on developing systematic methods of investigating outcomes based on interviews with staff, completion of a human factors questionnaire to assess the non clinical factors, e.g. supervision and communication issues which affected the staff performance and, finally, a review of the notes [2,4,5,6]. These methods help to build a detailed sequence of events during the incident, incorporating clinical and non-clinical factors operating within the event. After an adverse incident has occurred the staff involved in the incident are interviewed, using a set of pre-defined questions (this takes approximately 20-30 minutes). They are also asked to complete the questionnaire which enables staff to consider the organisational and environmental issues which may have affected their performance (e.g. poor communication, supervision problems, team functioning problems, etc.). The information generated from staff is then integrated to form a description of the event, which is supplemented with a review of the medical notes. For further information relating to this investigation process, see references [2,4,7].

Analysis of an adverse incident often reveals a series of errors combined with a set of unusual circumstances which together lead to a (potentially) catastrophic outcome. This kind of approach can reveal deep rooted unsafe features of organisations that are both inefficient and potentially dangerous. Investigation and analysis using this process allows clinicians to identify with more certainty why errors occur, which in turn enables the production of error reduction strategies to prevent future problems of a similar nature.

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Clinical Risk Unit/ALARM Protocol

This is available in PDF format:

Your comments

We value comments about your experiences of using the Investigation Protocol. We are planning to include more case examples in different healthcare settings. Please contact us with your comments.

* NB. Some have difficulty downloading the main protocol document, where only the first page is displayed and the remaining pages are blank. Please contact Maria for an attached PDF file if you experience this problem.


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References

  1. Vincent CA. (ed) Clinical Risk Management. BMJ Publications. 1995
  2. Vincent CA, Taylor-Adams S, Stanhope N. A framework for the analysis of risk and safety in medicine. British Medical Journal 1998; 316:1154-7
  3. Vincent CA, Reason JT. Human factors approaches in medicine. In Rosenthal M, Mulcahy L, (eds.) Medical mishaps: pieces of the puzzle. Open University (in Press).
  4. Stanhope N, Vincent CA, Taylor-Adams S, O'Connor A, Beard RW. Applying human factors methods to clinical risk management in obstetrics. British Journal of Obstetrics and Gynaecology 1997; 104:1225-1232.
  5. Taylor-Adams S, Vincent CA and Stanhope N. A method for analysing adverse events in medicine. Safety Science 1999; 31:143-159.
  6. Taylor-Adams SE, Vincent C. Clinical accident analysis: understanding the complex interactions between the task, individual, team and organisation. In Vincent C, De Mol B (eds.) Safety in Medicine. Elsevier Science, 2000, 101-16.
  7. Vincent CA, Bark P. Accident Investigation: Discovering why thing go wrong. In Vincent CA. (ed) Clinical Risk Management, BMJ Publications, 1995, 391-410.

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This page was last updated on 12 February 2002. Comments.