Incident analysis is a structured process, focused on system improvement, that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. Analysis is a core component of incident management therefore it is important to ensure it is thorough, fair, unbiased and the recommended actions provide effective safety solutions.
The guidelines below may be adapted in accordance with local policies and procedures, the nature of the incident and the method of analysis selected. As new information about the incident is acquired, previous steps may need to be revisited (e.g. conducting additional interviews to explore new contributing factors) or a change may be needed to the analysis method (e.g. moving from a concise analysis to a comprehensive or multi-incident analysis.)
Understand what happened.
- Expand on the preliminary review by synthesizing additional information gathered from incident report(s), the health record, physical evidence, contextual factors, site visit(s), and interviews with those directly or indirectly involved in the incident
- Create a detailed timeline, collating facts from various sources
- Review additional supporting information such as any related policies and procedures, training materials, or evidence-based guidelines
- Consider that a literature review, environmental scan, expert consultation, or analysis of similar incidents may also be indicated depending on the scope and method of analysis
Determine how and why it happened.
- Identify contributing factors related to the incident, both those that increased the risk of harm and those that reduced the risk of harm or limited its impact
- Consider aspects of the incident that extend beyond the patient-provider level by probing all influencing factors and circumstances
- Use systems thinking, human factors methods and guiding questions that prompt an exploration of all system components to avoid cognitive biases and keep the analysis focussed on system-based factors
- Use diagramming or other analytical tools to identify and understand the relationships between and among contributing factors
- Document discrepancy(ies) in information from conflicting sources and the consensus reached by the analysis team as to the most appropriate direction based on the available information
- Articulate concisely what was found in a summary of findings that provides the backbone for the development of recommended actions
Identify what can be done to reduce the risk of recurrence and make care safer.
- Develop recommended actions addressing the analysis findings and that are specific, measurable, attainable, realistic and timely
- Ground recommended actions in evidence whenever possible, utilize the most effective solutions given the circumstances and target them to the appropriate system level(s) to achieve sustained improvement
- Propose an order of priority for recommended actions based on the degree of change required, ease of implementation, organizational factors, and influences from the external environment
- Review and validate the recommended actions with the patient/family, providers and experts (whenever possible)
- Prepare and hand-off the incident analysis report to those responsible for approving recommended actions, allocating the necessary resources, delegating implementation of the recommended actions and monitoring progress
- Include a tracking tool with assigned responsibilities and timeframes in the report to facilitate ongoing monitoring of the recommended actions and their outcomes
- Once the recommended actions and their order of priority is approved by the leadership team, and in accordance with organizational policies and applicable legislation, communicate them in a timely manner to the patient/family (post-analysis disclosure), providers, management, public and others as needed
Identify and share what was learned.
Share the learning gained from the analysis (outcome of recommended actions implemented and other changes made to improve safety) within the organization (staff, patient/family, individual who reported the incident) and beyond to prevent additional harm and to make care safer.