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PSNet: Patient Safety Network
Journal Article
Commentary

Safety analysis over time: seven major changes to adverse event investigation.

Vincent C, Carthey J, Macrae C, et al. Implementation Science. 2017;12.

In-depth review and analysis of adverse events can both inform and detract from progress in patient safety. This commentary suggests that the early event analysis approaches have not achieved their potential. The authors describe changes needed to improve incident analysis methods, including engaging patients and families in assessments and investigating a longer time period to understand the full patient care experience.