S2) Incident Investigations and Systems Approach
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Illustrate healthcare as a complex sociotechnical system in terms of the following: • Culture • Policies • Goals • FInancial context • Legal context
Illustrate James Reason’s Swiss Cheese Model
Provide some examples of active failures
• Slips and lapses • Violations • Mistakes
Provide some examples of latent conditions
• Time pressures • Understaffing • Faulty equipment • Fatigue • Unworkable procedures
What is a systems approach?
A systems approach is a set of elements (people, processes, info, organisations, software, hardware, etc) that when combined have qualities that are not present in any of the elements themselves
Where should we apply a systems approach?
Systems approach to: • Incident investigations • Improvement following incident investigations
What is a root cause analysis?
A root cause analysis is a structured approach to the retrospective investigation of adverse events (usually SIs) in healthcare focusing on the identification of the underlying factors (latent) causing the problem(s)
A root cause analysis aims to answer 3 questions. What are these?
• What happened? • Why did it happen? • What can be done to prevent it from happening again?
What is a serious incident?
A serious incident is an event in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff/organisations are so significant, that they warrant using additional resources to mount a comprehensive response
There is no definitive list for never events. However, provide some examples
Never events are acts and/or omissions that result in: • Unexpected/ avoidable death • Unexpected/ avoidable injury that leads or could have led to harm
Describe the process of incident reporting and investigation in the NHS
Account for the questionable quality of root cause analysis investigations
• Difficulty in placing all the right people in the same room • Sources of varying quality • Non- participation
What are the sources of varying quality in root cause analysis investigations?
• No black box • Medical notes / rotas / staff interviews and statements • Recall affected by hindsight bias