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Following through after completing an incident analysis consists of implementing the final recommended actions, monitoring their impact on safety, and when the goals and sustainability are achieved, transitioning to ongoing operations.  This step involves change and improvement, it spans over a longer period of time, and it is vital in demonstrating that the incident management process improved safety and quality of care.

 “Local leaders should ensure that they, or someone they designate, periodically observe care practices to ascertain if recommended actions have been implemented and sustained. By following through important insights and potential hazards and/or opportunities to patient safety can be discovered.”
-- Toolkit Faculty

Recommended strategies

Implement recommended actions.

  • Engage frontline staff and patients/families in the planning and implementation of recommended actions, exploring potential barriers and opportunities as well as mitigation strategies
  • Ensure ongoing leadership support and adequate human and financial resources for implementation
  • Use change management and improvement tools to base change on strong methodology
  • Incorporate a variety of communication strategies to maintain interest and engagement in the changes (e.g. small group and/or organization wide announcements in verbal and/or written format)
  • Test changes on a small scale to allow for feedback and refinement before broader implementation
  • Integrate the implementation of the recommended actions within the quality improvement and risk management actions (e.g. using a common platform) to monitor, report progress and align efforts

Monitor and assess the effectiveness of the recommended actions.

  • Rather than simply tracking the completion of recommended actions, establish relevant outcome, process and balancing measures to monitor whether the desired effect was achieved
  • Clearly define measures and design data collection to be as practical as possible
  • Monitor performance over time to demonstrate sustained improvement or lack thereof
  • Use all of the information available to evaluate the overall effectiveness of the recommended actions, including observations, stakeholder feedback, and unintended consequences
  • Revisit recommended actions that did not achieve the anticipated improvement and consider adjustments or alternate solutions

Close off the incident analysis and transition to ongoing operations.

  • Designate the incident analysis as complete once all of the recommended actions have been evaluated for a pre-determined period of monitoring
  • Determine if ongoing performance monitoring (such as unit or organizational quality indicators) is required to ensure sustainability
  • Guided by organizational policies and relevant legislation, communicate the status and impact of the recommended actions to the patient/family, staff, the person(s) who reported the incident, and senior leadership in a timely manner
  • If communicating results of recommended actions, respect patient/family preferences in terms what they want to know and when 
  • Celebrate successes and improvements highlighting the positive contributions to safety resulting from the incident management process