The Consequences for Incident Analysis

Every high-risk industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. Such industries employ many other methods for assessing safety but the identification and analysis of serious incidents and adverse events continues to be a critical stimulus and guide for safety improvement. Analyses of safety issues always require review of a range of information and recommendations should generally not be made on the basis of a single event. Nevertheless, an effective overall safety strategy must in part be founded on an understanding of untoward events, their frequency, severity, causes and contributory factors. In this chapter we consider how these analyses might need to be extended in the light of the arguments presented in the preceding chapters.

What Are We Trying to Learn When We Analyse Incidents?

A clinical scenario can be examined from a number of different perspectives, each of which may illuminate facets of the case. Cases have, from time immemorial, been used to educate and reflect on the nature of disease. They can also be used to illustrate the process of clinical decision making, the weighing of treatment options and, particularly when errors are discussed, the personal impact of incidents and mishaps. Incident analysis, for the purposes of improving the safety of healthcare, may encompass all of these perspectives but critically also includes reflection on the broader healthcare system.

A critical challenge for patient safety in earlier years was to develop a more thoughtful approach to both error and harm to patients. Human error is routinely blamed for accidents in the air, on the railways, in complex surgery and in healthcare generally. Immediately after an accident people make quick judgments and, all too often, blame the person most obviously associated with the disaster. The pilot of the plane, the doctor who gives the injection, the train driver who passes a red light are quickly singled out (Vincent et al. 1998). This rapid and unthinking reaction has been described by Richard Cook and David Woods as the 'first story' (Box 5.1). However while a particular action or omission may be the immediate cause of an incident, closer analysis usually reveals a series of events and departures from safe practice, each influenced by the working environment and the wider organizational context (Reason 1997; Vincent et al. 2000). The second story endeavours to capture the full richness of the event without the obscuring lens of hindsight and see it from the perspective of all those involved which should, ideally, include the perspective of the patient and family.

Box 5.1 First and Second Stories

The First Story represents how people, with knowledge of the outcome and the consequences for victims and organisations, first respond to breakdowns in systems that they depend on. This is a social and political process which generally tells us little about the factors that influenced human performance before the event.

First Stories are overly simplified accounts of the apparent cause of the undesired outcome. The hindsight bias narrows and distorts our view of practice after-the-fact. As a result, there is premature closure on the set of contributors that lead to failure.

When we start to pursue the Second Story our attention is directed to people working at the sharp end of the healthcare system and how human, organisational, technological and economic factors play out to create outcomes. We need to understand the pressures and dilemmas that drive human performance and how people and organizations actively work to overcome hazards (Adapted from Woods and Cook 2002)

We previously extended Reason's model and adapted it for use in healthcare, classifying the error producing conditions and organizational factors in a single broad framework of factors affecting clinical practice (Vincent et al. 1998; Vincent 2003). The 'seven levels of safety' framework describes the contributory factors and influences on safety under seven broad headings: patient factors, task factors, individual staff factors, team factors, working conditions, organisational factors and the wider institutional context (Table 5.1).

This gave rise to a method of incident analysis published in 2000, often referred to as ALARM, because it was produced with colleagues from the Association of Litigation and Risk Management (Vincent et al. 2000). The ALARM approach was primarily aimed at the acute medical sector. A later revision and extension in 2004, known as the 'London Protocol', has been translated into several languages and can be applied to all areas of healthcare including the acute sector, mental health, and primary care. The method of analysis is known by different names in different countries, with some continuing to use ALARM and other referring to the London protocol. We use the term ALARM/LONDON to describe the essential elements of the

Table 5.1 The ALARM/LONDON framework of contributory factors

previous versions, which is clumsy but avoids confusion. We also propose a new extended model, which we have christened ALARME to indicate the new European flavour that has been infused.

The approach developed by James Reason and others has been enormously fruitful and has greatly expanded our understanding of both the causes and prevention of harm. The question for us now is whether this perspective needs to be adapted or extended in the light of our previous arguments. The current model has been found to be effective in many different clinical settings but is primarily aimed at the analysis of relatively discrete events; it may need some revision if we are to also examine serious failures and harm that evolves over months or even years. We may need to broaden our approach to the investigation and analysis of incidents in a number of ways.