| Abstract | Objectives: To carry out a review of published and
unpublished work on the analysis on methods of
accident investigation in high-risk industries, and of
critical incidents in healthcare. To develop and pilot
guidelines for the analysis of critical incidents in
healthcare for the hospital sector, mental health and
primary care.
Data sources: Literature already available in the
Clinical Risk Unit, University College London. Work by
known experts in the field of accident investigation and
analysis. Electronic databases including PsycINFO and
MEDLINE. Websites for accident investigation reports.
Review methods: Twelve techniques from other highrisk
industries were reviewed in detail using criteria
developed for the purpose. This review provided a
conceptual framework for the healthcare review and
appraisal process, as well as providing a critical
assessment of the industry techniques. Rigorous
searching and screening identified 138 papers for
formal appraisal and a further 114 were designated as
providing potentially useful background information. A
formal appraisal instrument was designed, piloted and
modified until acceptable reliability was achieved. From
the 138 papers, six techniques were identified as
representing clearly definable approaches to incident
investigation and analysis. All relevant papers were
reviewed for each of the six techniques: Australian
Incident Monitoring System, the Critical Incident
Technique, Significant Event Auditing, Root Cause
Analysis, Organisational Accident Causation Model and
Comparison with Standards approach.
Results: All healthcare techniques had the potential of
being applied in any specialty or discipline related to
healthcare. While a few studies looked solely at death
as an outcome, most used a variety of outcomes
including near misses. Most techniques used
interviewing and primary document review to
investigate incidents. All techniques included papers
that identified clinical issues and some attempt to assess
underlying errors, causes and contributory factors.
However the extent and sophistication of the various
attempts varied widely. Only a third of papers referred
to an established model of accident causation. In most
studies examined there was little or no information on
the training of investigators, how the data was
extracted or any information on quality assurance for
data collection and analysis. There was some variation
in the level of expertise and training required but to
undertake the investigation to an acceptable depth all
required some expertise. In most papers there was little
or no discussion of implementation of any changes as a
result of the investigations. A quarter of publications
gave some description of the implementation of
changes, though few addressed evaluation of changes.
Conclusions: The reviews demonstrate that, while
much valuable work has been accomplished, there is
considerable potential for further development of
techniques, the utilisation of a wider range of
techniques and a need for validation and evaluation of
existing methods which would make incident
investigation more versatile and use limited resources
more effectively. Further exploration of techniques
used in high-risk industries, with interviews and
observation of actual investigations should prove
valuable. Existing healthcare techniques would benefit
from formal evaluation of their outcomes and
effectiveness. Studies should examine depth of
investigation and analysis, adequacy and feasibility of
recommendations and cost effectiveness. Examining
implementation of recommendations is a key issue.
Health Technology Assessment 2005; Vol. 9: No. 19
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