LEARNING FROM INVESTIGATION: EXPERIENCEWITH UNDERSTANDING HEALTHCARE ADVERSE EVENTS

摘要

Thorough, objective investigation of medical adverse events rarely happens due to the complexityof the environment, litigation, risk, and socio-political implications. Special concernscan, and do, undermine investigation depth, breadth, and quality. Healthcare’s distinct differencefrom other high hazard sectors requires a unique approach to adverse event investigation.We report on the initial results of a 15-month pilot program now underway to model anational healthcare investigation team. An example of adverse event investigation and organizationalresponse illustrates these issues.