Incident Investigation in Aging Services
March 25, 2020 | Healthcare Risk, Quality, & Safety Guidance
The investigation must begin directly after initial notification of the incident because time is a significant factor. The longer it takes to conduct fact-finding after an incident occurs, the greater the possibility that evidence will be lost, memories will dim, and speculation and self-justification will cloud the process. (ECRI "Healthcare Device")
Figure 1. Overall Postincident Response Process illustrates the many elements of postincident response in three phases. Incident reporting and initial investigation—the topics addressed in this white paper—occur in Phase I.
Postincident response is both ongoing and complex. Depending on the incident, the total process can occur over a long period of time. It comprises a series of identifications, valuations, decisions, internal and external notifications and reports, communications, evaluations and monitoring, analyses, and ultimately changes to care, delivery, and systems. Figure 2. Postincident Response Algorithm maps the events and processes that make up postincident response, including...