Investigating the causes of adverse events.
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001.
Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.