Safety analysis over time: seven major changes to adverse event investigation

Abstract

BackgroundEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.Main textThe primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects.We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.ConclusionsPrevious methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.

Pathology of poverty: the need for quality improvement efforts to address social determinants of health

“…Yet, poverty surely counts as the proverbial elephant in the room among contributing patient factors for so many issues affecting chronic disease management and quality problems more generally. A recent commentary by prominent patient safety experts calls for rethinking root cause analysis with a greater focus on the ‘patient journey’ across care settings, rather than restricting adverse event investigation to a single setting of care 17. For many patients, their journeys across settings of care cannot be understood, never mind improved, without attention to the socioeconomic context in which they occur.…”

Exploring normalization of deviance and examining factors that predict culture of safety in the operating room.

“…should continue to be a salient provocation in healthcare and play a role in guiding safety improvement strategies (Vincent, Carthey, Macrae, & Amalberti, 2017).…”

“…While historically, organizations generally focused on incident reports and investigative efforts to assess safety, there is wide acceptance that adding assessments that both anticipate safety risks and include human factors is needed in the future (Vincent, Carthey, Macrae & Amalberti, 2017). Therefore, assessing the occurrence of normalization of deviance and the reasons for its occurrence is highly warranted, particularly in the OR.…”

“…A culture of safety is critical to thwart errors in the OR, and therefore, it is imperative to examine the factors that support a culture of safety and those that may attenuate it. The identification and acknowledgement of patient safety threats and antecedents to adverse events should continue to be a salient provocation in healthcare and play a role in guiding safety improvement strategies (Vincent, Carthey, Macrae, & Amalberti, 2017). Singer et al (2009) concluded that a culture of safety within a healthcare facility was associated with higher levels of healthcare personnel safetyrelated behaviors and better patient outcomes, which established a link between a healthcare organization's culture of safety and patient safety.…”

“…Singer et al (2009) concluded that a culture of safety within a healthcare facility was associated with higher levels of healthcare personnel safetyrelated behaviors and better patient outcomes, which established a link between a healthcare organization's culture of safety and patient safety. It is essential to investigate OR personnel practice and safety culture, which is increasingly being recognized as an important strategy and a necessary precursor to improving the widespread deficits in patient safety (Pronovost & Sexton, 2005;Vincent, et al, 2017).…”