Building on a highly successful session at HFES 2004, this colloquium examined the issues that are bear on the success or failure of medical accident investigation and analysis. In-house investigations by panels without sufficient accident analysis training and expertise do not produce results that educate their own or other institutions. Thorough, objective investigation of medical adverse events rarely happens due to the complexity of the environment, litigation, risk, and socio-political implications. Healthcare adverse event data collection and analysis relies on impartial, qualified investigators who have detailed domain knowledge and the use diverse investigation methods. This half day session reviewed the tenets of accident investigation and analysis, identified and examined obstacles to obtaining thorough, detailed, and insightful results, and compared healthcare to other high hazard sectors with regard to accident investigation criteria. It also presented participants with the description of an adverse event that will challenge them to develop their own notion of investigation needs, obstacles and strategies.  

Adverse events, or accidents, in healthcare can have significant clinical outcomes including loss of property, health (morbidity), and life (mortality). The investigation and analysis of medical accidents is intended to discover information that explains the nature and cause of what occurred in the interest of preventing or minimizing future loss. However, healthcare accidents have features that make post-event investigations particularly difficult. Thorough, objective investigation of medical adverse events rarely happens due to the complexity of the environment, litigation, risk, and socio-political implications.

Healthcare organizations have no impartial national resource on which they can rely to investigate accidents. As a result, each healthcare institution is responsible to develop its own program using the resources that are available at hand. Healthcare organizations currently create their own panels to investigate adverse events at their own facility. The “safety” programs that result in such an environment are designed to meet the approval of the hospital’s accrediting organization when it conducts a review. This arrangement amounts to a social contract that works well until an event occurs that draws attention of the public and regulatory organizations such as state medical boards. Each healthcare organization’s safety committee tends to be comprised of administrative and medical staff members who have little to no experience in systems analysis or accident investigation. Members of safety committees do not have the benefit of the same level of education, training and insight as the practitioners who are involved in an incident. Workers and managers within a system tend to view almost everything about that system as unchangeable except for the most superficial local factors. Locally-conducted analyses seem to focus on what is described as “operator error” because the panel’s scope of action is largely limited to influencing local conditions instead of broader agendas such as device design or regulatory policy. The local committee approach sheds more light on why institutions can't deal with adverse outcomes than on the nature of the events they seek to understand.  

Reason (1997:18) has described a process of accident analysis for any complex system: start with a bad outcome, consider how and when defenses failed, establish what active failures and latent conditions were involved (for each defense that was bypassed or breached), consider what local conditions could have shaped or provoked each unsafe act, and ask what upstream factors could have contributed to each local condition. Cook, Woods, and Miller, (1998) have demonstrated the use of a parallel approach to understand the role that practitioners play in operating demand-driven complex technical systems such as healthcare. Beyond process, though, it takes deliberate effort to create the kind of environment that makes effective adverse event investigations possible. The nature of risk management encompasses a much greater range of elements than a single field of practice or even a single hospital. Failure to account for those elements ignores many of the aspects that influence how each facility operates. Insights into adverse events flow from diverse, not uniform, points of view. Rasmussen (1998) described the relationships among various disciplines that are involved in risk management. Professionals in engineering, human performance, organization and management, and the social sciences can, and should, be available in order to bring insight to the accident investigation. Each of these disciplines understands the nature of action, judgment and plans at the work and staff levels. Professionals in law, economics, sociology and political science have insight into the activities of regulators, associations and the government. Other high hazard sectors have already addressed the issue of a large scale organization to deal with adverse events. For example, the National Transportation Safety Board (NTSB) exists to examine accidents and provide findings to the benefit of all concerned with transportation. While opinions may vary regarding their methods, NTSB investigators are considered to be technically competent and have developed an organization and procedures that serve accident investigation well.  

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