ABSTRACT
The investigation of adverse events can be decomposed into a number of different activities. For example, data must be collected about the events that led to a mishap. Interviews and the analysis of data logs and charts provide the infor mation that is necessary to understand what hap pened. Elicitation techniques may also extend more widely into the organizational and managerial con text in which an incident occurred. Together these different sources of information can contribute to our understanding of why there was an accident or near miss. Any causal analysis, in turn, helps to guide the identification of recommendations that are ulti mately intended to minimize the likelihood of any future recurrence. It is important to stress that these different activities often overlap so that, for instance, it is often necessary to gather additional evidence to support particular causal hypotheses. Similarly, the identification of potential recommen dations often forces analysts to reconsider their interpretation of why an adverse event occurred. The U.S. Joint Commission on Accreditation of Healthcare Organizations (https://www.jcipatient safety.org/show.aspPdurki = 9348, 2004) identified similar stages when it argued that a “meaningful improvement in patient safety” is dependent on:
• “Identification of the errors that occur. • Analysis of each error to determine the
underlying factors-the “root causes”— that, if eliminated, could reduce the risk of similar errors in the future.
