How not to run an incident investigation

Incident investigation is an integral feature of perioperative surgical safety programs and is likely to be fundamental in directing future initiatives. Advances in clinical practice and biomedical technology make the challenge of doing effective incident investigation more complex and nuanced. There is a palpable distance between the stable incident investigation activities of quality and safety departments and the continually evolving scope of surgical practice necessitating increasingly risky and complex procedures, requiring clear communication across clinical disciplines, and ongoing adjustment to the subtle changes in workplace conditions. Incident investigation should not be a remote activity of senior management disconnected from everyday practice in the perioperative setting but a functional tool for discovering fresh insights about the challenging aspects of the local clinical workplace in context. Local experience and expertise are important factors in shaping a culture of good clinical judgment and decision-making. However, clinicians remain ambivalent about incident investigation processes and tend to find more value in the informal debriefing conversations that start up after an adverse event across the organization. Perhaps the establishment of local review meetings and departmental debriefings is the most vital aspect of any incident investigation process. A good and timely debrief shifts the conversation from a retrospective search for isolated causes to a prospective exploration of patterns and cues in the local clinical workplace that emerge from everyday activity over time. Nonetheless, it is commonplace for hospitals and health service providers to use structured methods for the analysis of adverse events, the determination of contributing factors, and the implementation of corrective actions to improve the safety and performance of clinical systems (e.g., root cause analysis in combination with human factors engineering). Incident investigation typically involves a broad range of techniques for gathering and arranging the facts that relate to adverse events into a report that categorizes areas of breakdown and vulnerability in the interactions within a clinical micro-system. Investigation methods have become systematized and organized over time around a predetermined set of procedures to produce the required data. However, it does not follow that incidents need to be investigated according to a fixed scheme. Above all, clinicians need to have the authority and inclination to shape the investigation process to achieve the ends that they most value in their particular workplace.