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Quality and Safety

Easy Guide to Clinical Incident Management

Time lines for investigation

RCAs for SAC 1 incidents must be completed within 70 days. SAC 2, SAC 3 and SAC 4 investigations must be completed within 28 days of notification. All investigations must begin as soon as practicable so that important information is not lost

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Step 4. Investigation

Page 12 - 15 of the Policy
Covered in this page are SAC 1 investigations | SAC 2 investigations | SAC 3 and SAC 4 investigations

The manager leads the investigation of incidents at the local level.

SAC 1 and SAC 2 incidents are given high priority. Resources are allocated as necessary, and they are conducted at the highest level in the organisation. Irrespective of the priority of action, however, the same principles underpin all investigations: We want to know what happened, how it happened, and how to prevent it happening again.

SAC 1 investigations

In NSW, legislation mandates that all clinical SAC1 incidents are investigated using the Root Cause Analysis process. The documentation involved in this process is covered by statutory privilege. See the literature review and see also the RCA Team Leaders website (Intranet only). The Clinical Practice Improvement and Root Cause Analysis flow diagram in the Easy Guide to Clinical Practice Improvement provides an overview of the steps involved. The timetable for completing the RCA process is shown in the following table.

SAC 2 investigations

A clinical risk manager and/or clinical expert or a multidisciplinary team or expert serious-event review panel can conduct investigations of SAC 2 incidents. The documentation produced in SAC 2 incidents is not covered by statutory privilege. A good method for investigation SAC 2 incidents is The London Protocol (the Protocol), which has been adapted from investigative applications outside healthcare.

The Protocol outlines a full investigation for serious incidents, but it is possible to adapt the basic approach to many different settings and approaches. It has been used for quick 5–10 minute analyses by identifying only the main problems and contributing factors.

The steps in the Protocol's process are:

  • Identification and decision to investigate
  • Selection of investigators
  • Data gathering
  • Determination of incident chronology
  • Identification of care delivery problems
  • Identification of contributory factors
  • Recommendations and action plan.

For more on the London Protocol, refer to Taylor-Adams S, Vincent C 2004, Systems analysis of clinical incidents: The London protocol.

SAC 3 and SAC 4 investigations

SAC 3 and SAC 4 incidents are investigated at the local level using simple techniques, such as the 5 Whys, barrier analysis, and change analysis. Refer to the Easy Guide to Clinical Practice Improvement for other tools, such as cause and effect diagrams and brainstorming.

The 5 Whys

Barrier Analysis

Change analysis

This simply involves asking "why" five times until the root cause of the incident is revealed.

Why did the elderly patient slip going to the toilet?

  1. Why? Patient was given wrong medication.
  2. Why? Nurse was attending a handover meeting and did not know the patient was at risk of falling.
  3. Why? Meetings are held elsewhere in the facility and staff do not complete fall risk assessments.
  4. Why? The handover system needs attention and staff have not received training on risk assessment.
  5. Why? There have been infrequent team meetings to review incidents and address staff training needs.

There are four types of barriers to preventing incidents from occurring:

  1. Physical, eg. locked door, mandatory fields in a computer program.
  2. Natural, eg. distance, time.
  3. Human action, eg. checking patient's ID
  4. Administrative, eg. policies, protocols and guidelines.

The most effective are Physical and Natural barriers. The least effective are those that rely on human action, such as developing policies.

Barrier analysis asks three questions:

  1. What barriers are in place, eg. policies and procedures, that act as a barrier to an incident occurring?
  2. What barriers failed?
  3. What barriers should be in place to prevent the recurrence of the incident

This involves comparing two similar situations: one where there has been an incident and another that was incident-free. This is useful if you are unsure where to start or the causes are not easily identifiable.

Steps in change analysis:

  1. Map out the events of the situation that resulted in the incident.
  2. Map out the steps of the incident-free situation.
  3. Compare the two processes.
  4. Identify any changes in the process.
  5. Consider if these changes had any effect on the process.
  6. If so, consider why these changes occurred (may need to use the 5 Whys, barrier analysis).
  7. Develop actions to address identified causes.