How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol

doi:10.1136/bmj.320.7237.777

BMJ 2000;320:777-781 ( 18 March )

Education and debate

How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol

Charles Vincent, reader in psychology ^a, Sally Taylor-Adams, lecturer ^b, E Jane Chapman, clinical risk and medicolegal manager ^c, David Hewett, assistant medical director ^d, Sue Prior, clinical risk coordinator (family services) ^d, Pam Strange, assistant nurse director (quality and risk) ^e, Ann Tizzard, delivery suite manager ^f.

^a Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT, ^b Department of Psychology, School of Health and Life Sciences, University of Aston, Birmingham B4 7ET, ^c North West London Hospitals NHS Trust, Harrow HA1 3UJ, ^d Winchester and Eastleigh Healthcare NHS Trust, Winchester SO22 5DG, ^e Bromley Hospitals NHS Trust, Orpington BR6 8ND, ^f St Michael's Hospital, United Bristol Healthcare NHS Trust, Bristol BS2 8EG

Correspondence to: C Vincent c.vincent@ucl.ac.uk

The first 150 words of the full text of this article appear below.

Why do things go wrong? Human error is routinely blamed for disasters in the air, on the railways, in complex surgery, andin health care generally. However, quick judgments and routineassignment of blame obscure a more complex truth. The identificationof an obvious departure from good practice is usually only thefirst step of an investigation. Although a particular action oromission may be the immediate cause of an incident, closer analysisusually reveals a series of events and departures from safe practice,each influenced by the working environment and the wider organisationalcontext. This more complex picture is gaining acceptance in healthcare, ¹ ² but it is seldom put into practice in the investigationof actual incidents.

Table Removed (Available Only in the Full Text)

The Clinical Risk Unit has developed a process of investigation and analysis of adverse events for use by researchers.^3-7Two years ago a collaborative research group was formed betweenthe unit and . . . [Full text of this article]

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Building a framework for trust: critical event analysis of deaths in surgical care: A M Thompson and P A Stonebridge
BMJ 2005 330: 1139-1142. [Extract] [Full Text] [PDF]

Reducing error, improving safety: Victor Barley, Graham Neale, Christopher Burns-Cox, Paul Savage, Sam Machin, Adel El-Sobky, Anne Savage, Aziz Sheikh, Brian Hurwitz, C K Connolly, Pia Maria Jonsson, Göran Tomson, Lars Räf, Ken McCune, Ron Law, Roger M Goss, Anonymous, Carlos A Estrada, James Carter, Clyde Brooks, Ann C Jobe, Jonathan Aldridge, Peter Freeland, Brenda Ashcroft, Max Eistein, Nicholas Boreham, Peter J Shirley, Leo Strunin, Maldwyn Morgan, Paul Cartwright, and Robert P Coffey
BMJ 2000 321: 505. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

Berenholtz, S. M., Hartsell, T. L., Pronovost, P. J. (2009). Learning From Defects to Enhance Morbidity and Mortality Conferences. American Journal of Medical Quality 24: 192-195 [Abstract]
WEISS, A. P. (2009). Quality Improvement in Healthcare: The Six Ps of Root-Cause Analysis. Am. J. Psychiatry 166: 372-372 [Full text]
JAYARAM, G. (2009). Dr. Jayaram Replies. Am. J. Psychiatry 166: 372-373 [Full text]
Benhamou, D., Auroy, Y., Amalberti, R. (2008). Monitoring Quality and Safety in Anesthesia: Are Large Numbers Enough?. Anesth. Analg. 107: 1458-1460 [Full text]
Berkenstadt, H., Haviv, Y., Tuval, A., Shemesh, Y., Megrill, A., Perry, A., Rubin, O., Ziv, A. (2008). Improving Handoff Communications in Critical Care: Utilizing Simulation-Based Training Toward Process Improvement in Managing Patient Risk. Chest 134: 158-162 [Abstract] [Full text]
Fisseni, G., Pentzek, M., Abholz, H.-H. (2008). Responding to serious medical error in general practice--consequences for the GPs involved: analysis of 75 cases from Germany. Fam Pract 25: 9-13 [Abstract] [Full text]
Kirk, S., Parker, D., Claridge, T., Esmail, A., Marshall, M. (2007). Patient safety culture in primary care: developing a theoretical framework for practical use. Qual Saf Health Care 16: 313-320 [Abstract] [Full text]
Aboumatar, H. J., Blackledge, C. G. JR, Dickson, C., Heitmiller, E., Freischlag, J., Pronovost, P. J. (2007). A Descriptive Study of Morbidity and Mortality Conferences and Their Conformity to Medical Incident Analysis Models: Results of the Morbidity and Mortality Conference Improvement Study, Phase 1. American Journal of Medical Quality 22: 232-238 [Abstract]
Stebbing, C., Wong, I. C K, Kaushal, R., Jaffe, A. (2007). The role of communication in paediatric drug safety. Arch. Dis. Child. 92: 440-445 [Abstract] [Full text]
van Beuzekom, M, Akerboom, S P, Boer, F (2007). Assessing system failures in operating rooms and intensive care units. Qual Saf Health Care 16: 45-50 [Abstract] [Full text]
Runciman, W B, Williamson, J A H, Deakin, A, Benveniste, K A, Bannon, K, Hibbert, P D (2006). An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care 15: i82-i90 [Abstract] [Full text]
Shojania, K. G., Fletcher, K. E., Saint, S. (2006). Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.. ANN INTERN MED 145: 592-598 [Abstract] [Full text]
Blike, G. T., Christoffersen, K., Cravero, J. P., Andeweg, S. K., Jensen, J. (2005). A Method for Measuring System Safety and Latent Errors Associated with Pediatric Procedural Sedation. Anesth. Analg. 101: 48-58 [Abstract] [Full text]
Thompson, A M, Stonebridge, P A (2005). Building a framework for trust: critical event analysis of deaths in surgical care. BMJ 330: 1139-1142 [Full text]
Schmidek, J M, Weeks, W B (2005). Relationship between tort claims and patient incident reports in the Veterans Health Administration. Qual Saf Health Care 14: 117-122 [Abstract] [Full text]
Tang, B., Hanna, G. B., Joice, P., Cuschieri, A. (2004). Identification and Categorization of Technical Errors by Observational Clinical Human Reliability Assessment (OCHRA) During Laparoscopic Cholecystectomy. Arch Surg 139: 1215-1220 [Abstract] [Full text]
Healey, A N, Undre, S, Vincent, C A (2004). Developing observational measures of performance in surgical teams. Qual Saf Health Care 13: i33-i40 [Abstract] [Full text]
Armitage, G., Holder, A., Hodgson, I. (2004). Using ethnography (or qualitative methods) to investigate drug errors: A critique of a published study. Journal of Research in Nursing 9: 379-387 [Abstract]
Vincent, C A (2004). Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 13: 242-243 [Full text]
Woolf, S. H., Kuzel, A. J., Dovey, S. M., Phillips, R. L. Jr (2004). A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors. Ann Fam Med 2: 317-326 [Abstract] [Full text]
Kuzel, A. J., Woolf, S. H., Gilchrist, V. J., Engel, J. D., LaVeist, T. A., Vincent, C., Frankel, R. M. (2004). Patient Reports of Preventable Problems and Harms in Primary Health Care. Ann Fam Med 2: 333-340 [Abstract] [Full text]
Bann, S, Darzi, A (2004). A protocol for the reduction of surgical errors. Qual Saf Health Care 13: 162-163 [Full text]
Woolf, S. H. (2004). Patient Safety Is Not Enough: Targeting Quality Improvements To Optimize the Health of the Population. ANN INTERN MED 140: 33-36 [Abstract] [Full text]
Woloshynowych, M, Neale, G, Vincent, C (2003). Case record review of adverse events: a new approach. Qual Saf Health Care 12: 411-415 [Abstract] [Full text]
Taxis, K, Barber, N (2003). Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care 12: 343-347 [Abstract] [Full text]
Vincent, C. (2003). Understanding and Responding to Adverse Events. NEJM 348: 1051-1056 [Full text]
Rothschild, J. M., Federico, F. A., Gandhi, T. K., Kaushal, R., Williams, D. H., Bates, D. W. (2002). Analysis of Medication-Related Malpractice Claims: Causes, Preventability, and Costs. Arch Intern Med 162: 2414-2420 [Abstract] [Full text]
Leape, L. L. (2002). Reporting of Adverse Events. NEJM 347: 1633-1638 [Full text]
Naish, J., Carter, Y. H, Gray, R. W, Stevens, T., Tissier, J. M, Gantley, M. M (2002). Brief encounters of aggression and violence in primary care: a team approach to coping strategies. Fam Pract 19: 504-510 [Abstract] [Full text]
Goldmann, D., Kaushal, R. (2002). Time to Tackle the Tough Issues in Patient Safety. Pediatrics 110: 823-826 [Full text]
Dean, B (2002). Learning from prescribing errors. Qual Saf Health Care 11: 258-260 [Abstract] [Full text]
Amoore, J., Ingram, P. (2002). Quality improvement report: Learning from adverse incidents involving medical devices. BMJ 325: 272-275 [Abstract] [Full text]
Wachter, R. M., Shojania, K. G., Saint, S., Markowitz, A. J., Smith, M. (2002). Learning from Our Mistakes: Quality Grand Rounds, a New Case-Based Series on Medical Errors and Patient Safety. ANN INTERN MED 136: 850-852 [Full text]
Wilson, T., Sheikh, A. (2002). Enhancing public safety in primary care. BMJ 324: 584-587 [Full text]
Crook, M (2002). Clinical governance and pathology. J. Clin. Pathol. 55: 177-179 [Abstract] [Full text]
Gosbee, J (2002). Human factors engineering and patient safety. Qual Saf Health Care 11: 352-354 [Abstract] [Full text]
Wilson, T., Pringle, M., Sheikh, A. (2001). Promoting patient safety in primary care. BMJ 323: 583-584 [Full text]
Neale, G., Woloshynowych, M., Vincent, C. (2001). Exploring the causes of adverse events in NHS hospital practice. JRSM 94: 322-330 [Abstract] [Full text]
Leape, L. L (2000). Reporting of medical errors: time for a reality check. Qual Saf Health Care 9: 144-145 [Full text]
Barley, V., Neale, G., Burns-Cox, C., Savage, P., Machin, S., El-Sobky, A., Savage, A., Sheikh, A., Hurwitz, B., Connolly, C K, Jonsson, P. M., Tomson, G., Räf, L., McCune, K., Law, R., Goss, R. M, Anonymous, , Estrada, C. A, Carter, J., Brooks, C., Jobe, A. C, Aldridge, J., Freeland, P., Ashcroft, B., Eistein, M., Boreham, N., Shirley, P. J, Strunin, L., Morgan, M., Cartwright, P., Coffey, R. P (2000). Reducing error, improving safety. BMJ 321: 505-505 [Full text]
TASKER, R. C (2000). Training and dealing with errors or mistakes in medical practical procedures. Arch. Dis. Child. 83: 95-98 [Full text]