1. Incident Management The Investigation

3. London Protocol System analysis Structured reflection Consistent approach Promotes openness

4. Root Cause Analysis Implication of one significant reason What happened & what caused it? Undirected brainstorming

6. Identification & Decision to investigate Organisation and information gathering Determine incident chronology Identify delivery problems Identify contributory factors Make recommendations and develop an action plan Select people for investigation team

7. Severity Assessment Code Consequence LikelihoodSeriousMajorModerateMinorMinimal Certain 11233 Almost Certain 11234 Likely 12234 Unlikely 12344 Highly Unlikely 23344

8. Vanita Hira 2011 follow up: Practice nurse to review immunisation processes i.e., how they are stored and current checking process. All staff to be informed of newly introduced processes. Scenario: A 2 year old child receives the 18 month vaccination in error. The incident is not noticed until the Nurse is filling in the child's immunisation record in the child's well child booklet. Investigation:  Brainstorming session between the nurses to determine how the nurse came to pick up the wrong vaccine and what if any processes were not followed or known

9. Vanita Hira 2011 follow up: Depending on investigation Documented responsibilities for checking and frequency of checks. established process for equipment checks. Scenario: Post an emergency situation it was noticed that the batteries of the DeFib were flat Assessment: event category F- equipment likelihood of incident reoccurring is possible, consequences of incident are serious = level 1 incident Investigation:  Team meeting to determine what processes are currently in place for checking  When was the last check by staff/supplier  Follow up with supplier.

10. The Team & Timing Select people for the team Gain a common understanding of the event Interview and gather all the information

11. The Timeline The team maps out the sequence of events The Care Delivery Problems are identified

12. Identify the Care Delivery Problems

13. Factor TypesContributory Influencing Factor Patient factors Condition (complexity and seriousness) Language and communication Personality and social factors Task and technology factors Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision-making aids Individual [staff] factors Knowledge and skills Competence Physical and mental health Team factors Verbal communication Written communication Supervision and seeking help Team structure (congruence, consistency, leadership etc) Work environmental factors Staffing levels and skills mix Workload and workflow patterns Design, availability and maintenance of equipment Administrative and managerial support Environment Physical Organisation and management factors Financial resources and constraints Organisational structure Policy, standards and goals Safety culture and priorities Institutional context factors Economic and regulatory context National health service & DHB executive Links with external organisations

15. The findings and action plan

16. Categories 1Clinical Administration6Blood or Blood Products11Patient Accidents 2Clinical Process7Nutrition12Falls 3Documentation8Oxygen / Gas13 Infrastructure/ Buildings/ Fittings 4 Health Care / Associated Infection 9Medical Equipment14 Resources/ Organisation/ Management 5Medication10Behaviour15Other WHO categories adjusted by HQSC

17. Six Monthly Review & Reporting Commonality of themes Inform Quality Improvement processes Looking for dis benefit from previous change Shared Learning Informing others in the Health system of their impacts Harm reduction