Who discovered/reported the event—role, not names
How it was discovered
The event itself
What happened—the type of adverse event
Where in the care process the event was discovered and/or occurred
When it occurred
Who was involved—functions, not names
Why—the most dominant cause based on a preliminary analysis
Likelihood of recurrence of similar adverse events
Severity of the event
Preventability of the event
Product information (blood, devices, drugs) if involved in the adverse event
Patient information, including age, gender, ethnicity, diagnoses, procedures, and comorbid conditions
On the basis of the above information, a decision should be made as to whether a formal root-cause analysis should be carried out (a similar decision is required to investigate a near miss; see Chapter 7). Using automated surveillance together with other detection methods will lead to the detection of a much greater number of adverse events that might warrant such an analysis than would otherwise be possible. All such events cannot feasibly be investigated. Thus if root-cause analyses are not focused on a critical subset, then (1) useless analyses will be carried out because there is no time to do them properly, and (2) effort will be devoted to performing root-cause analyses at the expense of testing and implementing real system changes that can reduce injury rates. The decision to carry out a root-cause analysis will normally depend on the following factors:
The likelihood of recurrence of similar adverse events—the assessment is facilitated by access to a database of adverse events. If a similar case has recently been investigated, full root-cause analysis will have only marginal utility.
The severity of the adverse event—can be assessed by direct observation.