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How Not to Run an Incident Investigation

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Surgical Patient Care

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Abstract

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.

“If you don’t inquire in a way that respects the intelligence of the other person, you probably won’t find many insights.”

—Gary Klein, Seeing What Others Don’t, 2013

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Author information

Authors and Affiliations

  1. School of Nursing and Midwifery, Hawkesbury Campus, Western Sydney University, Locked Bag 1797, Penrith, NSW, 2751, Australia

    Bryce R. Cassin RN, BA Hons (Class 1)

  2. Clinical Professor, Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Wayne State University School of Medicine, 5057 Woodward Avenue, Suite 13001, Detroit, MI, 48202, USA

    Paul Barach BSc, MD, MPH

Authors
  1. Bryce R. Cassin RN, BA Hons (Class 1)
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  2. Paul Barach BSc, MD, MPH
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Corresponding author

Correspondence to Bryce R. Cassin RN, BA Hons (Class 1) .

Editor information

Editors and Affiliations

  1. Department of Surgery Ascension Saint Agnes Hospital Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Juan A. Sanchez

  2. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA

    Paul Barach

  3. Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Julie K. Johnson

  4. Division of Cardiovascular Surgery Johns Hopkins All Children’s Heart Institute Johns Hopkins All Children’s Hospital, Johns Hopkins University, Saint Petersburg, FL, USA

    Jeffrey P. Jacobs

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Cassin, B.R., Barach, P. (2017). How Not to Run an Incident Investigation. In: Sanchez, J., Barach, P., Johnson, J., Jacobs, J. (eds) Surgical Patient Care. Springer, Cham. https://doi.org/10.1007/978-3-319-44010-1_41

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  • DOI: https://doi.org/10.1007/978-3-319-44010-1_41

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