S2) Incident Investigations and Systems Approach

Question 1

Illustrate healthcare as a complex sociotechnical system in terms of the following:

• Culture
• Policies
• Goals
• FInancial context
• Legal context

Answer 1

Question 2

Illustrate James Reason’s Swiss Cheese Model

Answer 2

Question 3

Provide some examples of active failures

Answer 3

• Slips and lapses
• Violations
• Mistakes

Question 4

Provide some examples of latent conditions

Answer 4

• Time pressures
• Understaffing
• Faulty equipment
• Fatigue
• Unworkable procedures

Question 5

What is a systems approach?

Answer 5

A systems approach is a set of elements (people, processes, info, organisations, software, hardware, etc) that when combined have qualities that are not present in any of the elements themselves

Question 6

Where should we apply a systems approach?

Answer 6

Systems approach to:

• Incident investigations
• Improvement following incident investigations

Question 7

What is a root cause analysis?

Answer 7

A root cause analysis is a structured approach to the retrospective investigation of adverse events (usually SIs) in healthcare focusing on the identification of the underlying factors (latent) causing the problem(s)

Question 8

A root cause analysis aims to answer 3 questions.

What are these?

Answer 8

• What happened?
• Why did it happen?
• What can be done to prevent it from happening again?

Question 9

What is a serious incident?

Answer 9

A serious incident is an event in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff/organisations are so significant, that they warrant using additional resources to mount a comprehensive response

Question 10

There is no definitive list for never events.

However, provide some examples

Answer 10

Never events are acts and/or omissions that result in:

• Unexpected/ avoidable death
• Unexpected/ avoidable injury that leads or could have led to harm

Question 11

Describe the process of incident reporting and investigation in the NHS

Answer 11

Question 12

Account for the questionable quality of root cause analysis investigations

Answer 12

• Difficulty in placing all the right people in the same room
• Sources of varying quality
• Non- participation

Question 13

What are the sources of varying quality in root cause analysis investigations?

Answer 13

• No black box
• Medical notes / rotas / staff interviews and statements
• Recall affected by hindsight bias