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INVESTIGATION OF CLINICAL INCIDENTS
The purpose of an investigation into a clinical incident is to fully understand what happened and to take forward any learning from this. Greater detail can be found in this BMJ article (BMJ 2000) https://doi.org/10.1136/bmj.320.7237.777).
An investigation can feel very distressing and probing to those involved. These feelings can be mitigated by understanding the purpose of the investigation and by the analysis being conducted in a culture of learning with no blame and one of maximising the learning to be gained.
The first step of an investigation is usually to understand how the processes and procedures involved deviated from the standards of good practice. Analysis usually reveals a series of events, each of which is influenced by the working environment and wider organisational context. The following are recommendations to those investigating a clinical incident:
- Investigation should focus less on individuals and more on organisational factors
- Use of a formal analysis protocol ensures a systematic, comprehensive, and efficient investigation
- The protocol reduces the chances of simplistic explanations and assignment of blame
Root cause analysis is the name given to the process most often used in healthcare to investigate clinical incidents. This is a process by which all the different perspectives of the incident are analysed e.g. clinical decision making, treatment options and the broader healthcare system.
If you have observed a Quality Committee, you will probably have observed the root analysis approach in practise.
The National Reporting and Learning System is managed and operated by NHS Improvement with the purpose of improvements to patient safety. Information how collected data is used to maximise the learning from clinical incidences can be found on the NHS Improvement website. When things go wrong in care, it is vital incidents are recorded to ensure learning can take place; learning means people working out what has gone wrong and why it has gone wrong, so that effective and sustainable actions are then taken locally to reduce the risk of similar incidents occurring again https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents