This recently published article in the New England Journal of Medicine provides a glimpse into the manner in which a growing number of medical organizations address clinical incidents. The author is a Professor of Psychology and Director of Clinical Safety Research Unit Imperial College of Science, Technology and Medicine in London, England.

Dr. Vincent addresses not only an aggressive and proactive method to investigate "clinical incidents," he provides a substantial discussion with respect to interacting with both victims of such incidents and those staff who are responsible for the errors in the first place.

What is immediately apparent from the context of Vincent's description of the appropriate methods to engage the clinical incidents that occur is the clear distinction between description and explanation that is common to our understanding of "investigation." (An investigation is the systematic collection of facts for the purpose of describing and explaining what occurred.) Vincent uses a different formulation. He first asserts that the investigative process must identify the "unsafe act," representing a person's or persons' "error or mistake." But merely describing the error or mistake is not sufficient, because there are antecedent factors that often caused that error to occur. According to Vincent:

...However, to understand how this mistake occurred, it is necessary to look further, back to the "error-producing conditions" that led to the unsafe act and to...decisions made by management and others that may have had a bearing on the outcome.

In other words, he treats his systems analysis as an opportunity to learn not only what happened, but why it happened. Clearly throughout the article Vincent urges the reader to think of incident management as a chance for the organization (and, by implication, the profession) to learn from errors, not merely find blame. He also uses the airline industry as an example of one sector where its high risk characteristics serve as a model to others -- including health care.

As an example of this interest, he provides the reader with a table identifying, "...Factors Influencing Clinical Practice and Contributing to Adverse Events." The table identifies several frameworks within which one might conduct analysis -- e.g., work environment, individual staff member, patient. It then identifies possible contributory factors and examples of specific that are likely to produce mistakes. For example, the following are the entries for "work environment."

Contributory Factors

Staffing levels and mix of skills;
Patterns in workload and shift;
Design of equipment;
Availability of equipment;
Maintenance of equipment;
Administrative & managerial support.

Examples of Problems that Contribute to Errors

Heavy workloads, leading to fatigue; limited access to essential equipment; Inadequate administrative support leading to reduced time with patients.

This type of analysis can be a model for the rest of us as we seek to use the online incident management tools not only to report and classify incidents, but most critically, to better protect people from harm.

Vincent has written a more comprehensive report on the systems analysis and investigative process briefly described in this article. It is a paper in the public domain created as a member of his University faculty (Department of Psychology). The article is titled, A Protocol for the Investigation and Analysis of Clinical Incidents. Any person is free to access the article in its entirety by following the preceding link.