The primary objective of incident analysis and management is to learn from the situation and ensure safer outcomes for future patients. An incident analysis includes a detailed description of the incident, analysis of underlying systems through a series of “how,” “why” and “what influenced this” questions in order to determine contributing factors, to formalize recommended actions related to improvements in processes or systems, and to document the findings and recommended actions and follow-through to identify and share learning.
Incident Analysis Collaborating Parties. Canadian incident analysis framework [Internet]. Edmonton: Canadian Patient Safety Institute; 2012. Figure 3.1, Incident analysis as part of the incident management continuum; [cited 2015 Jul 21]; p. 26. Available from: http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF
After recognizing that an incident has occurred and attending to the safety and well-being of the patient(s) and the provider(s) involved, the next step generally includes reporting so that further steps can be taken to manage the incident. Reporting assists in understanding the next steps, and is also the trigger for a chain of both internal and external notifications.
Effective and timely incident notification results in increased trust of all stakeholders, including the public. Internal notifications include the medical director as well as other individuals such as the attending physician, nurse manager and facility staff. External notification includes the College, as per the Bylaws, as well as other organizations as required by law.
The quality of incident analysis is extremely important for all involved. Medical directors play an integral role in ensuring that an incident analysis is conducted and in closing the loop by submitting a complete Reportable Incident Form to the Non-Hospital Medical and Surgical Facilities Program Committee.
Medical directors may find the Canadian Patient Safety Institute’s Incident Analysis Framework to be a useful resource in strengthening their incident analysis and reporting process.