The reason why things go wrong, particularly in complex systems such as healthcare and transportation, is often the result of a combination of factors. Human error is often cited as the cause of incidents, but it is often the result of a series of events and departures from safe practices that are influenced by the working environment and the wider organizational context.
The investigation of incidents in healthcare and other complex systems should not only focus on identifying the immediate cause of the incident, but also on understanding the underlying factors that contributed to the incident. These may include factors such as poor communication, inadequate training, lack of standardization, lack of resources, and poor organizational culture.
It's important to understand that human error is not always the result of carelessness or incompetence, but is often influenced by factors such as work environment, work schedule, and work culture. Therefore, it is important to investigate incidents from a systems perspective, rather than solely focusing on blaming individuals or specific actions.
By understanding the underlying causes of incidents, organizations can take steps to prevent them from happening again in the future. This requires a comprehensive investigation process that takes into account the entire organizational context, including the working environment, organizational culture, and the wider systems in which the organization operates.
Incident investigation is an important aspect of health services management (HSM) that involves identifying, analyzing and taking action to prevent the recurrence of unexpected events that could result in injury, loss or damage. This process helps organizations to identify and address the root causes of incidents, rather than just treating the symptoms.
The incident investigation process typically includes several key steps:
Reporting: Encouraging staff to report incidents and creating a culture of transparency and open communication.
Initial investigation: Gathering information about the incident, including the date, time, location, and circumstances surrounding the event.
Identification of the incident cause: Identifying the root cause of the incident using techniques such as the "5 Whys" method or a Fishbone diagram to trace the incident back to its origin.
Analysis: Analyzing the information gathered during the investigation to identify patterns, trends, and areas for improvement.
Recommendations: Develop recommendations for corrective and preventive actions to address the identified causes of the incident.
Implementation: Implementing the recommendations and monitoring the effectiveness of the actions taken.
Follow-up: Reviewing the incident and the actions taken to ensure that the incident does not recur and that the lessons learned are shared and integrated into the organization's policies and procedures.
Incident investigation is an important aspect of HSM because it helps organizations to identify and address the underlying causes of incidents, reduce the risk of recurrence, and improve the overall quality and safety of healthcare services.