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PSNet: Patient Safety Network
Journal Article
Study

A tool for the concise analysis of patient safety incidents.

Pham JC, Hoffman C, Popescu I, et al. Joint Commission journal on quality and patient safety. 2016;42:26-33.

Once identified, adverse events require investigation to understand underlying causes. Methodologies like root cause analysis are time and labor intensive, and the burden of subsequent investigation can lead to under-reporting of events. In this study, researchers tested a concise incident analysis method, drawing on multiple existing incident investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program. Participants found the tool to be comprehensible and usable, and most reported that they would continue to use it beyond the pilot phase. These results suggest that a more streamlined method of investigating adverse events could support patient safety improvement efforts.