The investigation of a clinical incident is an important component of an effective incident management system. All incidents notified in the Victorian Health Incident Management System (VHIMS) are allocated an incident severity rating and require an investigation or review process.
The three methodologies available to health services for investigating clinical incidents are:
- root cause analysis
- in-depth case review
- local investigation and aggregate review.
Clinical incident investigations and responsibilities
Victorian health services must investigate all clinical incidents, and clearly communicate the roles and responsibilities of all staff.
Clinical incident investigations - root cause analysis
Root cause analysis is a detailed and thorough investigation performed for sentinel events or critical incidents that have a severity rating of 1.
Root cause analysis (RCA) statements and reports
Root cause analysis statements and reports show the cause-and-effect relationships of an incident, and make recommendations to reduce the risk of recurrence.
Clinical incident investigations - in-depth case review
In-depth case reviews determine the intrinsic aspects of a system failure and identify opportunities for process improvement.
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