Investigation to Significant Incidents

The culture is never a name, blame and shame one, but rather a non-blame approach with emphasis on root cause identification and future prevention.  Healthcare professionals have to understand that adverse outcomes are practically inevitable because patients undergo high risk intervention and they usually start with conditions entailing risks.  No single worker is immune from problems and the management team knows it well, based on collective and personal experience.  When one person or team encounters a problem and even a mistake, open culture discussion prevents future occurence and saves others from falling into similar traps.  A panel approach delivers the most appropriate answers.

Chairman of the he Risk Management Committee usually heads the inquiry team, but the responsibility may be delegated to another colleague if appropriate.

There are usually clinicians from appropriate specialties, members of the Risk Management team, &  relevant professionals other than doctors.  At least one representative from general talents is useful because they offer new perspectives and angles of view.

December 20 2012