Expect the analytic phase to take at least several weeks. There are some helpful tools associated with many of the steps below. They can also be accessed from the sidebar to the right.
Patients and families, if able and willing, are among the most important witnesses for many adverse events. Interviewing them will enable the team to gain a more complete understanding of the event’s circumstances and may offer additional perspectives on how to reduce the risk of recurrence.
While it may be true that a human error was involved in an adverse event, the very occurrence of a human error implies that it can happen again. Human error is inevitable. If one well-intentioned, well-trained provider working in his or her typical environment makes an error, there are system factors that facilitated the error. It is critical to gain an understanding of those system factors to find ways to remove them or mitigate their effects.Here are two helpful tools:
Don't try to censor your own ideas. The team’s job is to identify and recommend the most effective actions possible. It is then leadership’s responsibility to weigh questions about risks, benefits, opportunity cost and impact on the system in general.