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Table 2 Seven major changes in adverse event analysis

From: Safety analysis over time: seven major changes to adverse event investigation

Change in practice



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