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- Second victim
- patient safety
- sentinel event
- root cause analysis
- patient outcomes
- medication error
- healthcare quality
In the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event.1 In the USA, the Joint Commission's Sentinel event policy and the Veterans Affairs hospitals' adoption of root cause analysis have made root cause analysis standard operating procedure.2 Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment.
There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors.3 There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes.4 5 A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors.6–11
Progress has been slower in translating policy into action at the level of the frontline clinician. The recent worldwide recession and soaring healthcare budgets have resulted in increased pressure on healthcare workers to do more with less. But in the years since, one question has remained: are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done?
In a typical incident investigation, the goal is to identify what happened, the problems that occurred in healthcare related to these events, and the factors that contributed to their occurrence. Information is extracted from physical artifacts, patient records and other documents, and witness statements.12
Once the sequence of events is made clear, there are three main considerations: the problems in care identified …