When Accidents Happen: Investigations That Create Future Safety

Given the continued high frequency of preventable harm in the healthcare industry, nurse leaders must be prepared to identify and respond to safety events. In addition, more healthcare organizations are understanding the criticality of high reliability and are invested in a more proactive approach to safety management. This chapter describes effective and practical methods, informed by safety science, for the investigation and mitigation of safety events. The indication for and application of apparent cause analysis, common cause analysis, failure mode and effects analysis (FMEA), and root cause analysis (RCA) are reviewed, and best practices are highlighted. A just culture framework is used to inform interviewing and meeting facilitation techniques with an emphasis on peer support. This chapter will also provide readers with an understanding of the importance of identifying the right tools to address a variety of situations and action items that consider human factors and are geared toward sustainability.