TRACEing the roots: A diagnostic 'Tool for Retrospective Analysis of Critical Events'

摘要

Objective: The lack of interdisciplinary clarity in the conceptualization of medical errors discourages effective incident analysis, particularly in the event of harmless outcomes. This manuscript integrates communication competence theory, the criterion of reasonability, and a typology of human error into a theoretically grounded Tool for Retrospective Analysis of Critical Events (TRACE) to overcome this limitation. Methods: A conceptual matrix synthesizing foundational elements pertinent to critical incident analysis from the medical, legal, bioethical and communication literature was developed. Vetting of the TRACE through focus groups and interviews was conducted to assure utility. Results: The interviews revealed that TRACE may be useful in clinical settings, contributing uniquely to the current literature by framing critical incidents in regard to theory and the primary clinical contexts within which errors may occur. Conclusion: TRACE facilitates a comprehensive, theoretically grounded analysis of clinical performance, and identifies the intrapersonal and interpersonal factors that contribute to critical events. Practice implications: The TRACE may be used as (1) the means for a comprehensive, detailed analysis of human performance across five clinical practice contexts, (2) an objective "fact-check" after a critical event, (3) a heuristic tool to prevent critical incidents, and (4) a data-keeping system for quality improvement.