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

BMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7237.777 (Published 18 March 2000)
Cite this as: BMJ 2000;320:777

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  1. Charles Vincent (c.vincent@ucl.ac.uk), reader in psychologya,
  2. Sally Taylor-Adams, lecturerb,
  3. E Jane Chapman, clinical risk and medicolegal managerc,
  4. David Hewett, assistant medical directord,
  5. Sue Prior, clinical risk coordinator (family services)d,
  6. Pam Strange, assistant nurse director (quality and risk)e,
  7. Ann Tizzard, delivery suite managerf
  1. a Clinical Risk Unit, Department of Psychology, University College London, London WC1E 6BT
  2. b Department of Psychology, School of Health and Life Sciences, University of Aston, Birmingham B4 7ET
  3. c North West London Hospitals NHS Trust, Harrow HA1 3UJ
  4. d Winchester and Eastleigh Healthcare NHS Trust, Winchester SO22 5DG
  5. e Bromley Hospitals NHS Trust, Orpington BR6 8ND
  6. f St Michael's Hospital, United Bristol Healthcare NHS Trust, Bristol BS2 8EG
  1. Correspondence to: C Vincent
  • Accepted 18 February 2000

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

Summary points

Analyses of clinical incidents should focus less on individuals and more on organisational factors

Use of a formal protocol ensures a systematic, comprehensive, and efficient investigation

The protocol reduces the chance of simplistic explanations and routine assignment of blame

Experience with the protocol suggests that training is needed for it to be used effectively

Analysis of incidents is a powerful method of learning about healthcare organisations

Organisational analyses lead directly to strategies for enhancing patient safety

The Clinical Risk Unit has developed a process of investigation and analysis of adverse events for use by researchers.37 Two years ago a collaborative research group was formed between the unit and members of the Association of Litigation and Risk Management (ALARM). This group has adapted the research methods to produce a protocol for the investigation and analysis of serious incidents for use by risk managers and others trained in incident analysis. The protocol gives a detailed account of the theoretical background and process of investigation and analysis together with case examples.8 In this article we introduce the main ideas …

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