Table 2 Seven major changes in adverse event analysis
From: Safety analysis over time: seven major changes to adverse event investigation
Change in practice | Current | Future |
|---|---|---|
Select some events identified by patients and families | Decision to investigate determined by organisational and regulatory priorities | Select some events with longer term chronologies identified by patients and families Ask patients to tell their story of the episode of care, focusing both on what went well and poorly. |
Widen the time frame of analysis: review the patient journey | Determine recent accident chronology | Widen the timeframe to the whole patient journey |
Fewer, deeper analyses | Give equal attention to all serious incidents | Prioritise events which must be explained to patients and families, thereafter, triage events to identify those with maximum potential for system-wide learning |
Success and failure in detection and recovery | Identify problems in process of care and contributory factors | Identify benefits of care as well as problems, and include detection and recovery from problems |
Examining safety issues and contributory factors at different time points | Identify contributory factors | Identify contributory factors to each individual problem and to detection and recovery |
Reflecting on the workability of the underlying care process | Assume the current standard of care as a given | Reflect on the feasibility and workability of current standards and practices and whether these need to be adjusted |
Broadening our repertoire of responses and recommendations | Recommendations and developing an action plan | Select from the full portfolio of strategies and interventions |