HEAL Early Intervention Toolkit: Investigating Adverse Outcomes

WHY IT MATTERS Investigating an adverse outcome quickly and thoroughly allows for earlier insight into the contributory causes. A thorough investigation should uncover what happened, and why it happened and assist in the identification of process improvement efforts that may be taken to improve outcomes. Planning for investigation processes will ensure readiness to respond in those crucial first hours and days. It will also ensure processes are centered on investigating facts, preserving evidence, and analyzing for improvement. Organizations should have a checklist for investigating adverse outcomes that includes prioritizing ongoing care, initiating a rapid investigation, completing an in-depth investigation, documenting, and protecting…