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Preparing for analysis consists of a preliminary review to determine the appropriate follow-up and whether a system-based incident analysis is needed.  If indicated, an incident analysis method, team, and approach are selected and initial interviews are conducted. The findings, actions and decisions made at this point in the incident management process influence the direction and effectiveness of the analysis process

Recommended strategies

Refer to your organization’s policies, procedures and jurisdictional requirements when implementing these steps.

Conduct a preliminary investigation.

  • Determine the most appropriate person to conduct the initial review and data gathering. Someone with formal incident analysis and patient safety training and/or accountability for patient safety is recommended  
  • Create a high level timeline and document the known facts related to the incident from currently available sources such as the incident report, the patient’s health record, and other documentation 
  • If appropriate, find out whether similar incidents or analyses have previously taken place within the organization and beyond to learn from their experience and approach

Select an analysis type and method.

  • Based on the preliminary understanding of what happened, and using appropriate guidance tools, determine whether a system-based analysis (focused on system improvement) or an accountability review (focused on individual performance) or both is required
  • A system-based analysis is not recommended for incidents that are thought to be the result of a criminal act or purposely unsafe act related to substance abuse by the provider, or involving suspected patient abuse
  • In situations where both a system-based analysis and accountability review are conducted, maintain a secure information firewall, i.e. no communication or influence between the two reviews
  • In the case of a system-based analysis, select the most appropriate analysis method (concise, comprehensive,  multi-incident) taking into consideration the complexity of the incident, the extent of its impact, and contextual factors  such as the likelihood of recurrence, regulatory mandates, and internal or external pressures

Identify the analysis team.

  • Guided by organizational policies and applicable legislative protection, establish an analysis team with clear roles and responsibilities captured in a team charter and clarify how confidentiality will be maintained
  • While team composition will vary depending on the incident, the involvement of frontline providers and leaders is paramount to the success of the analysis as they can advocate for and support change implementation,
  • The inclusion of a patient/family representative should be considered and is encouraged (e.g. a current or former patient of the service that was not directly involved in the incident being addressed)
  • The analysis team may include members from outside the organization depending on the context of the incident and  instances when the required content expertise does not reside within the organization, providers involved in the incident hold leadership positions, or when there is intense public scrutiny
  • Due to a variety of reasons including intense emotional response, some individuals involved in the incident may not be ready to participate; it is essential that the analysis team be understanding and keep the lines of communication open
  • It is recommended that primary responsibility for conducting, coordinating and reporting on the analysis is shared by a facilitator (with expertise in analysis) and a leader (with operational responsibility)

Coordinate meetings.

  • Before convening the team, gather all of the necessary information to conduct the analysis such as the patient’s health record, the timeline, pertinent equipment, relevant policies and procedures, and other documentation
  • Secure a comfortable and private setting
  • Emphasize and maintain confidentiality at all times to ensure information is only communicated in accordance with applicable policies and legislation
  • Manage documents in accordance with organizational policies

Plan and conduct interviews.

  • If feasible, meet with the team to confirm the approach and ground rules before conducting interviews
  • Invite the patient/family and staff to participate in interviews as appropriate, coordinating communication through the key contact assigned earlier
  • Conduct interviews as soon as is reasonably possible to help ensure that important information and details are recalled
  • Conduct interviews individually to provide an opportunity for those involved in the incident to share their detailed perspective and unique viewpoint
  • Consider the ability/readiness of the individuals being interviewed and provide care and support throughout:
    • clearly convey the purpose of the interview and what will be done with the information
    • favour the use of open-ended questions to allow the individual to tell their story
    • ask the individual whether they identified contributing factors related to the incident as well as factors they feel mitigated the outcome
    • pay particular attention to the needs of patients and family members during interviews, such as assisting with arrangements and logistics of the meeting, careful selection of the location to prevent further trauma, offering support, and providing a list of who will be there in advance