Understanding and responding to adverse events.
In this article, Vincent describes the investigation of adverse events and how to provide support to patients’ families and care providers in the wake of such events. Adapting Reason’s organizational-accident model, Vincent develops a framework of contributory factors that can be applied to a specific incident. He emphasizes the importance of identifying specific care management problems and analyzing them individually. Vincent outlines steps in the investigation process, highlighting specific sources of information an investigator might use. He also outlines steps for ensuring proper care of patients who have been harmed and providing adequate support for staff involved in the error.