Event Investigation and Analysis Guide: Appendix I
Adverse safety event: a deviation from generally accepted performance standards that reaches the patient and results in moderate to severe harm or death.
Anchoring bias: the tendency to make all information fit into a preconceived story, causing the interviewer to not seek out disconfirming evidence or make disconfirming evidence fit into the initial story. The initial piece of information is now used to make judgments about all other new information. Interviewers need to consider multiple perspectives and use factual information to uncover contributing factors to an event. If they are anchored, they will only seek evidence that confirms their initial hypothesis about the causes of the event.
Causal factor: the suspected or confirmed factors that caused the adverse event. Often, multiple factors must intersect for an adverse event to reach the patient. Labeling one or even several of these factors as "causes" may place undue emphasis on a single specific factor and obscure the overall relationships among different layers and other aspects of system design. The purpose of the event review and analysis is to help clarify the causal factors.
Contributing factor: additional elements that contributed to the adverse event, many of which are outside an individual’s control.
Confirmation and consensus meeting: a meeting where major stakeholders come together to determine critical contributing factors for a safety event.
Event review: the overall process of assessing an adverse safety event to determine contributing factors and develop solutions.
Hindsight bias: the tendency for people to exaggerate the likelihood that they could predict the event’s occurrence. In many events, those not involved tend to believe that they could have predicted the event and therefore avoided it. Hindsight bias is commonly driven by a lack of insight into the context of the error, meaning the details of the environment, information available to the provider at the time, and other factors that may not be initially obvious. It means sticking to a single explanation and failing to dig deeper, and it often means blaming others more than they ought to be blamed, simply because you feel like the causes of failure are obvious after the fact. For interviewers, it is important to remember this tendency and to consider the event in context. A systems approach principle is that no one wants to do a bad job; therefore, they thought they were doing their job correctly at the time. It is the interviewer’s job to find out why.
In-depth event review: the data-gathering phase of an event review, involving conducting interviews, making observations, and building a timeline.
Latent hazard: the hidden problems within health care systems that contribute to adverse events
Root cause: the underlying problems that increase the likelihood of errors. In a systems approach, root cause is referred to as contributing factor.
Solutions meeting: a meeting where major stakeholders and individuals who are able to make process changes come together to develop solutions and measurement plans for a safety event.
Stakeholder: typically managers and people who work in the process, the upstream and downstream departments, the patients, the support staff, and executive leadership. The team should note that not every group needs to be brought to the level of enthusiastic support for successful implementation of the plan.
Types of Solutions
Institutional: changes are large, facility-wide investments that require significant time and resources.
IT structure: solutions consist of changes to programs or interfaces that will change a process. These changes have the potential to be highly effective and sustainable if implemented after careful analyses to determine whether the technology supports the users.
Physical environment: any change to the environment, such as moving supplies to make them more accessible.
Process: solutions that change the workflow to reduce hazards, such as eliminating unnecessary steps. These include the accompanying changes to any protocols and necessary training.
Forms and paperwork: new forms or changes to documentation templates and procedures to improve communication and streamline processes.
Review: an assessment of a particular system or process with the aim of changing the studied process or environment. Reviews that are performed solely for compliance purposes are not included.
Training: educating individuals on new forms or procedures.
Policy: either reinforcement of existing policies or an isolated change to a policy that doesn’t require significant change to the underlying process, physical environment, or IT system. For the purposes of this toolkit, those policies changes can be bundled as part of those categories.
Compliance check: reviews of charts or processes for the purpose of monitoring or regulating a particular process. These solutions often use key words such as audits, chart reviews, and/or secret shoppers to verify that the process in question is being performed according to standards that are put in place.
Counseling: typically involve a "development plan," providing "feedback," or a practice committee referral to those involved in the event.
Contacting third party: includes hosting manufacturer representatives, motivational speakers, and other consultants.
Disciplinary: actions taken toward involved staff members.