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Commentary
To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.
May 5, 2021
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26(2):64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
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