Incident analysis: the resource for continuous improvement

Where people work, mistakes are made. There is simply no way around that. However, the question is how to learn from these mistakes as an organisation to take structural measures to eliminate causes. A thorough incident analysis helps with that.

Medication, aggression, infections, data breaches, etc., are some examples of things that frequently go wrong or very nearly so in healthcare. The consequences can be enormous. The greatest hurt from incidents usually concerns the suffering experienced by patients and staff. For instance, they fall, they are administered the wrong medication or something goes wrong in the handover between staff members. In addition, it can bring a hospital or healthcare facility negative publicity. Because of social media, mistakes are quickly big news with a bad image as a possible result. And what about the extra costs incurred to rectify the error and compensation claims that can be filed? Why do things go wrong despite all the precautions? What can we learn from an incident? And more importantly, what measures should be taken to prevent it from happening next time?

Start reporting incidents

Many organisations lack conducting a thorough incident analysis. Hence, a major cause of the mistakes still being made in the workplace, despite all precautions. In fact, an incident analysis is pre-eminently the tool for reporting and analysing incidents and deviations. Therefore, it is the primary source of improvements. Special incident software allows an employee to easily and quickly report an incident or abnormal situation. This can be done via computer, tablet, or cell phone. Today, the software is developed to link a consecutive action to the report automatically. Moreover, a file is built per incident, and you have all the information about that one report in one click.

Tips for reporting incidents:

• Make accident reporting as easy as possible for employees.
• Make sure employees know how to report an incident.
• Provide feedback on an employee’s report. For example, what was done with my report and what action will be taken? Employees’ sense of urgency decreases if no (or too late) feedback takes place.

What do we learn from reports?

An incident analysis is especially interesting because it provides an overview of all reports. Graphs, pie and bar charts visualise that very nicely. Think of an overview of incidents in a certain period, in a certain department or arranged by type of incident. How many reports are pending? Which incidents have been dealt with? And what improvement measures have been applied? In particular, visual mapping of reports, measures, and their status provide transparency for employees, managers and management. All this increases awareness at multiple levels and helps you get a grip on risks.

How do you ensure proper analysis?

Unfortunately, reporting and recording alone cannot prevent incidents. The most important thing is that an analysis takes place, and measures are taken on that basis. The core of an incident analysis is wanting to prevent errors and incidents. First of all, it is advisable to appoint one or two people to make thorough analyses. A good analysis stands or falls with its quality with an emphasis on thoroughness. Especially in high-risk incidents, a detailed analysis is necessary to identify the fundamental causes that led to the incident. These are often multiple causes on an organisational, technical, and human level.

What measures should you take?

The following (and final) step is to take structural measures. A challenging step. After all, there often turn out to be structural organisational or cultural errors behind individual mistakes made by employees. In other words, chances are very high that another colleague would have made the same mistake. In addition to recording and analysing at the organisational level, there is an increasing need to register and analyse deviations throughout the chain. For example, a patient often has to deal with multiple parties working together in the healthcare chain. This will only increase in the future, as tasks are increasingly placed in the hands of specialised parties. An incident analysis, therefore, contributes to improving and optimising cooperation throughout the chain.

Summary

Organisations that want to improve continuously, achieve their objectives, and get a grip on risks and costs cannot do without a good incident analysis. Registering incidents and deviations is the first step. Thanks to user-friendly software, registration can be done easily and quickly. It also provides insight and transparency into an organisation’s pain points. A thorough analysis is a next step: this exposes the root causes. Then, structural measures for improvement can be taken, especially with insight into the root causes.

Tips for analysis:

• Make a timeline of one incident first and then the cause tree.
• Organise a periodic theme-based approach. Register one specific type of deviation during a month, analyse the root cause the next month and report the conclusions and improvement actions in the third month. This will give you insight into how “big” a problem is in a short time. It also allows you to take adequate measures quickly. This increases alertness and support.
• Base the analysis purely on facts. Ask yourself “why?” five times before you get to the root cause.
• Don’t base conclusions on opinions and assumptions.
• Try to conduct the analysis as soon as possible after the deviation occurs.
• Classify causes so you can easily make analyses across incidents.