How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management Protocol

Department of Psychology, Aston University, Wheaton Aston, England, United Kingdom
BMJ Clinical Research (Impact Factor: 14.09). 04/2000; 320(7237):777-81. DOI: 10.1136/bmj.320.7237.777
Source: PubMed


Analyses of clinical incidents should focus less on individuals and more on organisational factors. Use of a formal protocol ensures a systematic, comprehensive, and efficient investigation. The protocol reduces the chance of simplistic explanations and routine assignment of blame. Experience with the protocol suggests that training is needed for it to be used effectively. Analysis of incidents is a powerful method of learning about healthcare organisations. Organisational analyses lead directly to strategies for enhancing patient safety.

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Available from: Charles Vincent, Jul 18, 2014
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    • "Within health-care settings, there have been various attempts to analyse adverse events from a human factors perspective. The most widely known approach is the London Protocol developed by Vincent et al. (2000). The Protocol prescribes a systematic process to analyse adverse events and is largely based on Reason's Organisational Accident Causation Model (Reason 1997). "
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    ABSTRACT: Various human factors classification frameworks have been used to identified causal factors for clinical adverse events. A systematic review was conducted to identify human factors classification frameworks that identified the causal factors (including human error) of adverse events in a hospital setting. Six electronic databases were searched, identifying 1997 articles and 38 of these met inclusion criteria. Most studies included causal contributing factors as well as error and error type, but the nature of coding varied considerably between studies. The ability of human factors classification frameworks to provide information on specific causal factors for an adverse event enables the focus of preventive attention on areas where improvements are most needed. This review highlighted some areas needing considerable improvement in order to meet this need, including better definition of terms, more emphasis on assessing reliability of coding and greater sophistication in analysis of results of the classification. Practitioner Summary: Human factors classification frameworks can be used to identify causal factors of clinical adverse events. However, this review suggests that existing frameworks are diverse, limited in their identification of the context of human error and have poor reliability when used by different individuals.
    Full-text · Article · Jul 2014 · Ergonomics
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    • "Mandatory reporting about serious adverse events protects society by guaranteeing that appropriate action is taken [2]. The analysis of adverse events is a powerful learning method within healthcare organizations [4]. High reporting rates are generally associated with a safety-focused culture [5,6], and increases in incident reporting are assumed to improve patient safety [7]. "
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    ABSTRACT: Objectives The aim of this study was to evaluate the effectiveness and sustainability of educational interventions to encourage incident reporting. Methods This was a quasi-experimental design. The study involved nurses working in two gastroenterology surgical wards at Fukuoka University Hospital, Japan. The number of participants on each ward was 26 nurses at baseline. For the intervention group, we provided 15 minutes of education about patient safety and the importance of incident reporting once per month for six months. After the completion of the intervention, we compared incident reporting in the subsequent 12 months for both groups. Questionnaires about reasons/motives for reporting were administered three times, before the intervention, after the intervention, and six months after the intervention for both the intervention group and the control group. Results For the intervention group, incident reporting during the 6 months after the intervention period increased significantly compared with the baseline. During the same period, the reasons and motives for reporting changed significantly in the intervention group. The increase in reported incidents during the 6- to 12-month period following the intervention was not significant. In the control group, there was no significant difference during follow-up compared with the baseline. Conclusions A brief intervention about patient safety changed the motives for reporting incidents and the frequency of incidents reported by nurses working in surgical wards in a university hospital in Japan. However, the effect of the education decreased after six months following the education. Regular and long-term effort is required to maintain the effect of education.
    Full-text · Article · Jul 2014 · Healthcare Informatics Research
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    • "Trainees and clinicians can learn about diagnostic failure by investigating and analysing real-world cases. A variety of different frameworks and tools are available to facilitate analysis, some of which are specific to settings or specialties.40–45 The ability to critique cases, identify contributing factors, map the diagnostic process and recognise problems and potential sources of error can provide opportunity for learning and strategies for improvement. "
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    ABSTRACT: Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.
    Full-text · Article · Jun 2013 · BMJ quality & safety
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