Critical incidents guide puts spotlight on patient safety

News release from the National Coordinating Centre for Health Technology Assessment

10 November 2005

Patient safety is the focus of a guide published as part of research commissioned by the HTA programme which aims to support clinicians, clinical teams and risk managers in dealing with accident investigation, analysis and prevention.

Produced by researchers as part of a project to identify the best ways to handle critical incidents and adverse events in healthcare, the guide details the best techniques for dealing with critical incidents in hospitals, mental health care settings and primary care. It has been produced following reviews of methods of accident investigation and analysis in both the healthcare setting and within other high risk industries by the research team, led by Professor Charles Vincent of the Clinical Safety Research Unit at Imperial College London.

As part of the research the team reviewed potentially relevant literature and found six techniques that offered clearly definable approaches to incident investigation and analysis. These included the Australian Incident Monitoring System (AIMS), the Critical Incident Technique, Significant Event Auditing (SEA), Root Cause Analysis (RCA), Organisational Accident Causation Model (OACM) and Comparison with Standards approach. All the techniques could be applied to the healthcare environment, most using interviewing and primary document review to investigate accidents, and all included papers which identified clinical issues with some attempting to assess underlying errors, causes and contributory factors. The research team has drawn the best points of the various techniques together to form a simple, practical guide.

"At a time when health and safety is a priority for all organisations, learning from accidents and near misses in the healthcare sector has lagged behind," explains Professor Vincent. "The idea of the guide is to enable clinicians to carry out comprehensive and thoughtful investigations and analyses of incidents, rather than the more usual steps of quick identification or assumption of fault and blame. Case examples from different specialities are given to illustrate the approach, with a simple format for presenting the analysis and recommendations."

The guide has been designed so that its approach can be adapted to different settings, whether the investigation is being carried out by a single person who would assemble and collate the information, carry out the interviews and then report back to the clinical team to consider action, or if a team with different skills and backgrounds is involved (as is more likely to be the case for a serious incident.) A research group comprising volunteers from the target sectors was specifically set up in order to test and pilot the draft guide, with changes and adaptations made based on experiences, comments and discussion. The guide is intended for use mainly within the context of local procedures and practices.

The full guide is available as part of ' The investigation and analysis of critical incidents and adverse events in healthcare,' published in the HTA programme's internationally acclaimed journal series Health Technology Assessment . The full text of the research monograph is available for download free of charge from http://www.hta.ac.uk/project/1145.asp

Notes:

  1. The Clinical Safety Research Unit (CSRU) was established in September 2002 with an initial grant from Smith and Nephew Foundation. The current programme builds on research developed over 15 years at the Clinical Risk Unit, University College . The CSRU maintains a broad research programme of research which aims to enhance the safety and quality of healthcare. For more information visit the Clinical Safety Research Unit website, www.csru.org.uk. 'Systems analysis of clinical incidents, the London protocol' is available for download free from this site, detailing an incident analysis method closely associated with the critical incidents guide.

Notes for editors


  1. The HTA programme is a programme of the National Institute for Health Research (NIHR) and produces high quality research information about the effectiveness, costs, and broader impact of health technologies for those who use, manage and provide care in the NHS. It is the largest of the NIHR programmes and publishes the results of its research in the Health Technology Assessment journal, with more than 400 issues published to date. The journal’s 2007 Impact Factor (3.87) ranked it in the top 10% of medical and health-related journals. All issues are available for download free of charge from the website, www.hta.ac.uk The HTA programme is coordinated by the National Coordinating Centre for Health Technology Assessment (NCCHTA), based at the University of Southampton.
  2. The National Institute for Health Research provides the framework through which the research staff and research infrastructure of the NHS in England is positioned, maintained and managed as a national research facility.  The NIHR provides the NHS with the support and infrastructure it needs to conduct first-class research funded by the Government and its partners alongside high-quality patient care, education and training.  Its aim is to support outstanding individuals (both leaders and collaborators), working in world class facilities (both NHS and university), conducting leading edge research focused on the needs of patients. www.nihr.ac.uk

Contact details

Naomi Stockley, Programme Manager (Communications)
Telephone: 02380 595 646, Email: ns5@soton.ac.uk

Helen Nikandrou, Assistant Programme Manager (Communications)
Telephone: 02380 595 584, Email: h.nikandrou@soton.ac.uk

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