Overview of mental health and addiction adverse event review methods, types and approaches
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The following overview aims to help clinicians better understand the various adverse event review methodologies available. This is not an exhaustive list and other methodologies may exist.
The Learning Review methodology is the method promoted by Te Tāhū Hauora as it better reflects the complexity of health care and reduces hindsight bias. The other methods are included as part of a toolkit that users may choose to explore further as resource allows.
The Healing, learning and improving from harm: National adverse events policy 2023 Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023 states that the review should reflect the eight policy principles. It is highly recommended that services consider how they bring an impartial lens to any review methodology used, as well as listening to and endeavouring to meet the needs and expectations of consumers, whānau and health workers involved.
Table of contents
- Learning Review
- London Protocol
- Concise incident analysis tool
- Root cause analysis (RCA)
- RCA2 (root cause analysis actions)
- AcciMap
- File/desk review
- Failure mode and effect analysis
- Yorkshire Contributory Factors Framework
- Facilitated restorative practice meetings
Review method
Learning Review[1]
Description
Designed for complex systems, particularly those involving people.
A social sense-making activity that reviews an accident, incident or even normal work for clues as to where staff contribute to the safety of operations or where the system inhibits this capacity.
Designed to facilitate the understanding of the factors and conditions that influence human actions and decisions by encouraging individual and group sense-making at all levels of an organisation.
When to use
Designed to be used with complex systems.
Strengths
Seeks to understand what led people to do what they did at the time.
Avoids use of ‘why’ questions.
Reduces hindsight bias.
Compares work as done with work as imagined.
Uses those doing the work as experts in how to do the work.
Informed by human factors and resilience engineering.
Weaknesses
Use of focus groups may be time intensive.
Training and resources available
Currently the focus of the Health Quality & Safety Commission’s Adverse Events Learning Programme education: www.hqsc.govt.nz/our-work/system-safety/adverse-events/education/adverse-events-learning-programme-workshops.
Open Book: Learning Review (March 2021): www.hqsc.govt.nz/resources/resource-library/open-book-learning-review-march-2021.
Interactive e-learning module in development (available early 2022) via the Health Quality & Safety Commission’s website.
Review method
London Protocol[2]
Description
A method that provides a comprehensive and thoughtful/reflective systems analysis of clinical incidents seeking areas for care improvement.
Uses the incident to reflect on what it reveals about the gaps and inadequacies in the health care system.
Most used and understood method in mental health and addiction (MHA) services in New Zealand.
When to use
Multifactorial complicated issues.
Multiple system cross-sector involvement.
Strengths
Review method is designed for use in health care.
Can be scaled up or down depending on the size of the event in question.
System focused.
Can provide independence if the review team includes a facilitator and some members from another part of the service.
Weaknesses
Contributory factors have been adapted for health care from other industries rather than created for health care.
Difficult to write truly systems-based recommendations without whole-of-sector input.
Can be hindsight biased.
Focuses on the actions of the people involved rather than the way the system performed.
Uses those involved in the incident to identify what went wrong and possible improvements. Reliving the event may be traumatic for those involved in it.
Implies a linear progression of adverse events.
Focus is on the review team as the experts rather than those doing the work.
Training and resources available
Training currently not available to everyone in New Zealand.
Practical resources available from the Systems Analysis of Clinical Incidents: The London Protocol webpage of the Institute for Health care Improvement website: www.ihi.org/resources/Pages/Tools/SystemsAnalysisofClinicalIncidentsTheLondonProtocol.aspx.
Overview video of London Protocol available on: www.youtube.com/watch?v=rAGf98WzpN8.
Review method
Concise incident analysis tool[3]
Description
Involves a conscious and deliberate decision to focus primarily on four aspects: the agreed upon facts, key contributing factors and findings, actions for improvement (if any), and evaluation.
An analysis by a person(s) with knowledge of the incident analysis process, human factors and effective solutions development in health care, with input gathered from consumers, whānau, staff and physicians local to the event as well as organisational or external experts.
When to use
Incidents that resulted in no or low harm to the consumer.
Incidents primarily limited to one work area, division or department.
New incidents for which a comprehensive analysis was recently completed.
Initial review to determine whether a comprehensive incident analysis is appropriate.
Strengths
Less resource intensive than other methods.
Uses a systems approach and considers human factors.
Weaknesses
Generally facilitated by one person, which may result in an overly narrow focus.
Abbreviated scope may not capture all causal factors.
Focus is on the review team as the experts rather than those doing the work.
Training and resources available
No training currently available for this in New Zealand.
Online training available at Geniozz: www.geniozz.com.
Review method
Root cause analysis (RCA)[4]
RCA2 (root cause analysis actions)[5]
Description
A systematic process for identifying the root causes of a problem or event and describing an approach to responding to them.
Asks three questions:
- What happened?
- Why did it happen?
- What can be done to prevent it happening again?
When to use
Uncomplicated events with few causal factors.
Linear events with low complexity.
Strengths
Can identify systems-based corrective actions.
Carried out by a multidisciplinary team.
Provides structure to the retrospective analysis of adverse events.
Weaknesses
Time and resource intensive.
Difficult to write truly systems-based recommendations without whole-of-sector input.
Implies a singular, linear cause.
Can be hindsight biased.
Can become focused on clinician deficit rather than systems factors.
Focus is on the review team as the experts rather than those doing the work.
Training and resources available
No training currently available for this in New Zealand.
Resources available on:
Review method
AcciMap[6]
Description
A systems-based technique for analysing events that occur in complex sociotechnical systems.
Looks at all levels of a system, from higher governmental and regulatory levels to the actual work being carried out.
Results in a graphical representation of the event.
When to use
Useful for complex events involving multiple levels of a system.
To examine the relationships between the different levels of a system.
Strengths
Identifies system-wide errors that led to the event.
Simple to learn and use.
Considers causal factors across systemic levels.
Provides a visual representation of the event aetiology.
Enables extended timeline of causality to be established as it considers different levels.
Looks beyond the organisational level.
Weaknesses
Can be time consuming.
Quality of analysis produced is dependent on the quality of the investigation.
Does not provide a method to develop corrective measures.
Does not provide a structured taxonomy for error classification.
Its graphical output can become hard to decipher when used for very complex events.
Focus is on the review team as the experts rather than those doing the work.
Training and resources available
No training currently available for this in New Zealand.
Resources available on: https://systemsthinkinglab.com.
Review method
Description
Review of a clinical record to identify issues and make recommendations to address an issue; can be used as a standalone review or diagnostic to trigger a more in-depth methodology.
This may sometimes be enhanced by selected interviews and/or a review conducted by someone outside that clinical unit.
When to use
Initial review to determine whether a comprehensive incident analysis is appropriate.
Usually indicated when the initial triage of an incident raises no specific issues of concern in terms of systems, processes and care delivery.
Strengths
Requires minimal resources.
Can be completed by an independent reviewer if required.
Can be used as a triage process to decide if a more in-depth review is required.
Weaknesses
May not gather all relevant information.
Can be hindsight biased.
Focus is on the reviewer as the expert rather than those doing the work.
Review method
Failure mode and effect analysis (FMEA)[7]
Description
A systematic method of identifying and preventing product and process problems before they occur. It is proactive and does not rely on something going wrong as the trigger for an investigation.
When to use
Before implementing a new process.
Before altering an existing process.
Strengths
Particularly useful in evaluating a new process before implementation and in assessing the impact of a proposed change to an existing process.
Weaknesses
May not identify all potential failures.
Requires large amounts of time, effort and resource.
Teams may require sources of information other than personal experience and knowledge.
Training and resources available
No training currently available for this in New Zealand.
Online training available at:
Other approaches to support adverse event review processes
Approach to review processes
Yorkshire Contributory Factors Framework[8]
Description
An evidence-based framework that has been specifically developed for the health care setting.
This is not a review method as such but can be used to strengthen other methods.
When to use
Describes both latent organisational failures and the error-producing conditions in which active failures occur.
Gives a greater weighting to systems rather than human failings.
Strengths
Developed by clinicians in a health setting.
Weaknesses
Developed in a hospital setting so may not be applicable to out-of-hospital care settings.
Does not include a consumer perspective of the causes of incidents.
Training and resources available
No training currently available for this in New Zealand.
Approach to support review processes
Facilitated restorative practice[9] or hohou te rongo[10]
Description
Facilitated restorative practice meetings between consumers and/or whānau and staff involved in care, as soon as practicable after the event.
When to use
This can be an important process that complements adverse event review rather than replaces it.
Strengths
The focus is on engagement, healing relationships, addressing harm to all parties (including affected staff) and promoting wellbeing rather than identifying cause and attributing blame.
Aligns with other forms of investigation analysis and tools.
Weaknesses
New in health care.
Can be resource intensive in terms of time, staff and training.
Training and resources available
Health Quality & Safety Commission’s Adverse Events Learning Programme virtual adverse events training.
Phase 2 of the national mental health and addiction (MHA) quality improvement programme ‘Learning from adverse events and consumer, family and whānau experience’ project.
Content finalised December 2021; published February 2022.
Endnotes
- Pupulidy I, Vesel C. 2017. The Learning Review: Adding to the accident investigation toolbox. URL: www.safetydifferently.com/the-learning-review-adding-to-the-accident-investigation-toolbox.
- The London Protocol: https://healthmanagement.org/c/hospital/issuearticle/the-london-protocol.
- Canadian Patient Safety Institute. 2014. Concise incident analysis tool: A resource for health care organization. URL: www.patientsafetyinstitute.ca/en/toolsResources/Research/commissionedResearch/IncidentAnalysisMethodPilotStudy/Pages/default.aspx.
- US Department of Veterans Affairs, Root Cause Analysis: www.patientsafety.va.gov/media/rca.asp.
- National Patient Safety Foundation. 2015. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation. URL: www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx.
- Svedung I, Rasmussen J. 2002. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Safety Science 4: 397–417.
- Shebl NA, Franklin BD, Barber N. 2012. Failure mode and effects analysis outputs: are they valid? BMC Health Services Research 12: 150.
- Yorkshire Contributory Factors Framework: www.improvementacademy.org/tools-and-resources/the-yorkshire-contributory-factors-framework.html.
- Ministry of Health. 2019. Hearing and Responding to the Stories of Survivors of Surgical Mesh. Wellington: Ministry of Health. URL: www.health.govt.nz/publication/hearing-and-responding-stories-survivors-surgical-mesh.
- Peace-making from a te ao Māori world view. This process addresses harm by restoring the mana, power, authority and tapu of people and their relationships. www.hqsc.govt.nz/our-work/system-safety/healing-learning-and-improving-from-harm-policy/restorative-practice-and-hohou-te-rongo.
Bibliography
Lawton R, McEachean RR, Giles SJ, et al. 2012. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Quality & Safety 21: 369–80. doi: 10.1136/bmjqs-2011-000443.
Peerally M, Carr S, Waring J, et al. 2017. The problem with root cause analysis. BMJ Quality & Safety 26(5): 417–22. doi:10.1136/bmjqs-2016-005511.
Scion. 2017. Guide to Doing a Learning Review. Rotorua: New Zealand Forest Research Institute Limited (Scion). URL: https://safetree.nz/wp-content/uploads/2017/11/Guide-to-doing-a-learning-review-Nov-2017.pdf.
Shebl NA, Franklin BD, Barber N. 2012. Failure mode and effects analysis outputs: are they valid? BMC Health Services Research 12: 150. doi:10.1186%2F1472-6963-12-150.
Taylor-Adams S, Vincent C. 2001. Systems Analysis of Clinical Incidents: The London Protocol. London: National Patient Safety Agency, Clinical Safety Research Unit, Imperial College London.
Vincent CA. 2004. Analysis of clinical incidents: a window on the system not a search for root causes. BMJ Quality & Safety 13: 242–3.
Wu AW, Lipshutz AK, Pronovost PJ. 2008. Effectiveness and efficiency of root cause analysis in medicine. JAMA 299(6), 685–7.
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