Health Technology Assessment 2005; Vol 9: number 19
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M Woloshynowych,1* S Rogers,2 S Taylor-Adams3 and C Vincent1
1 Clinical Safety Research Unit, Imperial College London, UK
2 Department of Primary Care and Population Studies, University College London, UK
3 National Patient Safety Agency, London, UK
* Corresponding author
In other high-risk industries, learning from accidents and near misses is a long-established practice, in fact it is a cornerstone of safety analysis and improvement. In contrast, learning within healthcare has often been fragmentary and uncertain. In the last 10 years, however, sufficient work has accumulated within healthcare to warrant a review of methods of investigation and analysis, supplemented by a parallel overview of methods of investigation and analysis in other settings.
The objectives of the review were:
The diversity of techniques used in other industries greatly impressed us, as did the clarity with which they were presented and the power and conceptual development of some of the methods. A search of relevant databases, websites and specialist literature yielded 19 accident investigation and analysis techniques. Of these, 12 were selected and reviewed in detail. All had some strong points, although the approaches varied in comprehensiveness, theoretical adequacy, use of resources and the extent to which they were used and accepted. Some techniques stood out as being of particular value. For instance, MORT (Management Oversight and Risk Tree), if carried out completely, is an extremely comprehensive technique examining an accident from several perspectives using a toolbox of techniques. Many of these techniques provide useful methods of solving specific accident investigation or analysis problems. For example, barrier analysis is an exceptionally quick and useful approach to identifying where and how to implement specific types of defences and barriers within an organisation.
Initial searches on electronic and other databases identified 1950 potentially relevant papers. After screening of abstracts, 562 papers were obtained for further review. After further screening, 138 papers were identified for formal appraisal and a further 114 were designated as providing potentially useful background information.
A formal appraisal instrument was designed, piloted and modified until acceptable reliability was achieved. From the 138 papers, six techniques were identified as representing clearly definable approaches to incident investigation and analysis. We excluded from formal appraisal those techniques which had been used in less than five peer-reviewed published studies. All relevant papers, to a maximum of ten, were reviewed for each of the six techniques: Australian Incident Monitoring System (AIMS), the Critical Incident Technique, Significant Event Auditing (SEA), Root Cause Analysis (RCA), Organisational Accident Causation Model (OACM) and Comparison with Standards approach.
All techniques had the potential to be applied in any specialty or discipline related to healthcare. Although a few studies looked solely at death as an outcome, most used a variety of outcomes including near misses. Most techniques used interviewing and primary document review to investigate incidents. All techniques included papers which identified clinical issues and some attempt to assess underlying errors, causes and contributory factors. However, the extent and sophistication of the various attempts varied widely. Only one-third of papers referred to an established model of accident causation. In most studies examined there was little or no information on the training of investigators, how the data were extracted or any information on quality assurance for data collection and analysis. There was some variation in the level of expertise and training required, but to undertake the investigation to an acceptable depth all required some expertise. In most papers there was little or no discussion of implementation of any changes as a result of the investigations. One-quarter of publications gave some description of the implementation of changes, although few addressed evaluation of changes.
The review of methods of accident investigation in high-risk industries showed that there are a number of potentially useful techniques that could be used in healthcare. Review of techniques used in healthcare revealed two of particular interest and potential, RCA and OACM, but there were also methodological developments in other approaches that might be transferable (e.g. group-based approaches in SEA, taxonomies from the monitoring studies, links to implementation in audit and peer review approaches). Our learning from these techniques underpins the guide that appears in this publication. For three specialities, acute care, mental health and primary care, a research group was set up to test and pilot a draft version of the guide. Changes were then made following their experiences, comments and discussions. The resulting guide is included in Chapter 6 of the report, with case examples in the corresponding appendix.
The principal recommendations were as follows.
Manuals and descriptions of the methods of investigation and analysis need to be developed. Researchers need to provide much more detail on the purpose of the technique, its context of use and the process of investigation.
High-risk industries recognise that accident investigation is a specialist and complex task, which requires substantial investment in training dedicated accident investigators. Healthcare professionals engaged in investigations also need adequate training and experience. Local teams need sufficient time to enable them to produce a thorough report with serious attention to implementing changes.
Both researchers and investigation teams need to give more attention to recommendations for change and implementation of changes. Research studies cannot always consider the whole cycle of investigation, analysis, implementation and evaluation, but as the techniques develop more attention should be given to linking findings directly to future prevention.
The range of effective approaches available in high-risk industries suggests that investigators of clinical incidents should think in terms of a toolbox of approaches, where specific techniques would be used for different purposes and at different stages of an investigation.
Our reviews demonstrate that, while much valuable work has been accomplished, there is considerable potential for further development of techniques, the utilisation of a wider range of techniques and a need for validation and evaluation of existing methods, which would make incident investigation more versatile and use limited resources more effectively.
Further exploration of techniques used in high-risk industries, with interviews and observation of actual investigations, should prove valuable. Existing healthcare techniques would benefit from formal evaluation of their outcomes and effectiveness. Studies should examine depth of investigation and analysis, adequacy and feasibility of recommendations and cost-effectiveness. Examining implementation of recommendations is a key issue.
Woloshynowych M, Rogers S, Taylor-Adams S, Vincent C. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess 2005;9(19).
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