Action is required to reduce harm and prevent future events
Before review, information is gathered and processed
Continually ask “why” the event occurred
Develop recommendations to prevent recurrences
Event data for similar events can improve actions taken
Flowcharts demonstrate visually what happened and what should have happened
Goal of the incident investigation is to identify risk areas
Have measures in place to prevent or reduce harm in the future
Identifying the root-cause is critical to resolution
Joint Commission root-cause analysis for sentinel events can be utilized in the office setting
Keep records of interviews, event data and correspondences
Latent errors in existing processes can require review
Main goal is to identify the problem and correct it
No risk in office processes is a fallacy
Organization-wide actions should be implemented, rather than just in the area involved
Process investigation will help identify the areas of concern
Question of the hour, “Why did it happen?”
Root-cause analysis is a process
Specify “what should be done to prevent recurrence”
Team members analyzing the issue should have multiple skill sets and understand the process
Ultimate goal “prevent future occurrences”
Validate the “fix” by monitoring the process
“What’s the problem?” is the most important question. Identify the issues at hand
Xpecting error-free performance is unattainable, but repeating the error is unacceptable
You can’t measure what you can’t identify
Zero tolerance for patient harm
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