Serious events that result in harm to patients leave a mark on a hospital, and all those involved. But, depending on the approach taken by investigators of the event, these events can teach valuable lessons that will positively impact future patient care.
In general, there are two types of approaches to serious event investigations. One investigation approach is focused on cause identification and prevention, while the other is focused on determining and minimizing liability. For any given event, it may be necessary to deploy both of these methods of investigation. But, in almost any case, they should be separated to prevent contamination of purpose.
Cause and Prevention Investigation
The goal of cause and prevention investigations is to uncover what caused or contributed to the occurrence of the serious event, to identify ways to prevent the event from recurring, and to mitigate the effects of the event. The multidisciplinary, investigative team must look beyond direct causes of the event and search for factors that led to or influenced those direct causes. By examining the context of the event as well as the proximate causes, investigators can recommend changes that will decrease the likelihood of recurrence.
Investigating a serious event through a liability-based approach takes on a different character. Largely directed by the risk manager or in-house counsel, this type of investigation focuses primarily on accountability and the risks the event poses to the organization from the legal and public relations perspectives.
While the response to every serious event must consider the legal impact on the organization, decisions based solely on liability concerns can limit the opportunity to develop improvements. The outcome of these types of investigations is usually a set of precise actions directed at only a few proximate causes of the event. This type of investigation, in short, provide evidence that the expectations of regulatory authorities have been met. However, these investigations often fail to go further. By neglecting to identify underlying issues, they deny hospitals the valuable opportunity to impact similar events in the future.
Often, organizations do not consciously choose to focus solely on liability. Rather, this inclination represents the culture of the organization as a whole. Leaders who have lived through serious (and often public) events in the past may be tempted to “circle the wagons” and minimize scrutiny of the process failures that caused the adverse event. Others in the organization may fear that a thorough cause and prevention investigation will derail other priorities and consume scarce time.
Creating a Culture of Openness
Thus, organizational leadership is critical to good cause and prevention investigations. Because these investigations require honesty and an absence of defensiveness, leaders must foster a culture of trust and safety. Often, the errors that feed adverse events are circumstance-related. To uncover these circumstances, employees must feel safely able to discuss the conditions surrounding the event. When cause and effect investigations and liability investigations are linked, event participants may be unwilling to disclose crucial information if they feel it might jeopardize their employment.
Creating the right atmosphere requires hospital leaders make a commitment to cause and prevention investigations and the separation of liability concerns from prevention goals. Leaders must also ensure employees that it is safe to speak openly and honestly with investigators. Defining this position before an event occurs will help those involved to step back from the emotions spurred by serious events. By focusing on finding ways to prevent conditions that lead to serious events, leaders can send a clear message about the importance of safety throughout the organization.