Much of the focus on serious incident investigations is on the “How?”. People give a lot of thought to the processes, policies and procedures around investigations – not to mention to the filling in of template documents. The focus is on getting the job done.
In our experience there isn’t always so much attention on the question of what the investigation is for – what it is that the process is trying to achieve. If you aren’t clear about the objective, it is difficult to do something well.
And there is only one thing that really matters with all of this – knowing what has gone wrong and putting it right.
As well as advising about SI investigations, we also help people with backlogs of incident investigations. One of the most common comments we get to on SI reports is for the to include more information, more detail. Obviously an investigation isn’t complete if it doesn’t tell the story. But is more detail always a good idea? Collecting lots of information can be time consuming – and therefore expensive. That is particularly important if it is being done by clinicians who would rather be spending their time helping patients directly. Most of all, irrelevant data can serve to obscure the true picture, and restrain the improvement of patient safety in the NHS and beyond. People can get bogged down in unimportant details, and fail to see the bigger picture. It is helpful for patients and families too to be given a clear explanation of the relevant evidence, rather than having to pick out for themselves what is really material.
How do you strike the right balance – ensuring that you have all the information that you need, without spending time you don’t have? We thought about this issue a lot when designing Eva. It aims to take you through each stage of an investigation and collect the information that you need to draw conclusions – and identify the necessary actions needed. We believe that this is one thing that makes Eva’s untoward incident investigation software an invaluable tool for investigators.
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