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Recommendations for detailed analysis of the incident

  • Ensure that information is reported in an appropriate context and through an appropriate medium addressing all questions as openly and honestly as possible as they arise.
  • Activate the team responsible for conducting the root cause analysis (as appropriate).

Suggested bibliography: How to perform a root cause analysis for workup and future prevention of medical errors – a review: Charles R, Hood B, Derosier JM, Gosbee JW, Li Y, Caird MS, et al. How to perform a root cause analysis for workup and future prevention of medical errors: A review. Patient Saf Surg [Internet]. 2016;10(1):1–5. Available from: http://dx.doi.org/10.1186/s13037-016-0107-8

  • Arrange a meeting of the Safety Committee to analyse the results of the case analysis or root cause analysis (as appropriate) and propose measures to increase patient safety.
  • Establish the information required and a deadline for reporting it, minimising delays.
  • Decide whether it is appropriate to invite representatives of registered patient associations to participate in the case analysis or root cause analysis (as appropriate).
  • When needed, inform the patient who has experienced the adverse event (or his/her family) of the results of the analysis. This could be useful in some cases.
  • Introduce measures to increase patient safety and assess their effectiveness.
  • With the appropriate confidentiality, hold clinical sessions to discuss medical errors and how to decrease the risk of them occurring in the future.
  • Reflecting on the experience of an adverse event, review procedures for ensuring that personal information disclosed about patients and health professionals after an adverse event with media impact respect their rights to confidentiality and personal privacy. Consider that once agreement has been reached on measures to improve procedures and avoid adverse events due to a similar cause in the future, it is not relevant or necessary to provide further information, remembering also that relevant information has been noted in the patient’s medical record.

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