Essential Concepts of ALARME

The ALARM/LONDON approach set out a methodology and structured approach to reflection on the many factors that may contribute to an incident. During an investigation information is gleaned from a variety of sources: Case records, statements and other relevant documentation are reviewed and interviews are carried out with staff and ideally with the patient and family. Once the chronology of events is clear there are three main considerations: the care delivery problems identified within the chronology, the clinical context for each of them and the factors contributing to the occurrence of the care delivery problems. The key questions are: What happened? (the outcome and chronology); How did it happen? (the care delivery problems) and Why did it happen? (the contributory factors) (Vincent et al. 2000).

In the context of this book there are four new issues to be considered:

• First, we need to look at a broader class of events which impact on the patient.

Some events for analysis need to be selected from the patient's point of view in addition to those identified by professionals.

• Second, we need to extend the analysis to examine an episode in the patient journey rather than a single incident. The timeframe is widened to include the whole 'event journey'. ALARME proposes an extended approach that applies the classic grid of contributory factors to each of the identified care delivery problems in the unfolding story of the 'emerging harm' considered for initial analysis

• Third, we need to pay more attention to both successes and failures of detection, anticipation and recovery. We need to consider not only problems but also success, detection and recovery and how they combine to produce the overall ratio of benefit and harm for the patient. This in turn affects the nature of the learning and the subsequent safety interventions that we might recommend

• Fourth, we potentially have to adapt both methods of analysis and recommendations to the different contexts and models of safety

Our expanded process of investigation maintains the basic approach of ALARM/ LONDON and the original table of contributory factors, but extends the time frame and includes analysis and reflection on success, detection and recovery (Fig. 5.1 and Table 5.2). The changes we propose would require significant research and investment in the development of new methods but we believe this is essential if safety is to be effectively managed across clinical contexts.

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