How Not to Run an Incident Investigation



Incident investigation is an integral feature of perioperative surgical safety programs but clinicians remain ambivalent about the investigation processes that health services use for the analysis of adverse events. Developing insight into the way complex human systems interact and making connections within perioperative environments requires a shift in mindset about incident investigations. The decisions about the process and techniques for analyzing adverse events are best made at the operational level. This approach directs the inquiry toward what is knowable about an event in its local context rather than making assumptions based on general categories. Findings are then more likely to be disseminated when they relate to how the perioperative workplace is experienced. A strategy for workplace learning is required that can be tailored to local dynamic conditions. Tools and techniques that test the reliability of local clinical systems and the efficacy of local system design provide a useful adjunct to incident investigation. An adverse event should not be viewed in isolation from the particular nuances of perioperative work. Unlocking system insight involves building a local workplace culture for learning from experiences in a supportive environment.


Incident investigation Adverse events Complex systems Workplace learning System insight 


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Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.School of Nursing and Midwifery, Hawkesbury CampusWestern Sydney UniversityPenrithAustralia
  2. 2.Clinical Professor, Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research ScholarWayne State University School of MedicineDetroitUSA

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