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Event Investigation Guide
Use the reliable How? When? Where? Who? What? and Why? questions in a consistent manner to assure that you have examined all elements of and influences on the event.
Answer and document all of the following questions concerning the event in question:
HOW was the event identified or discovered?
WHEN was the event identified or discovered?
- When did the event happen? – At what time?
WHERE did the event occur?
- Describe location and any unusual elements of the environment and location.
WHO has direct knowledge of the event?
- Who discovered or identified the event and how did they do so? – How did the event come to their attention?
- Who reported the event and how did they do so? – How did the event come to their attention?
- Who was directly involved in the event?
- other staff (e.g., nurse aides, therapists, secretaries)
- family members/visitors
- How were each of the individuals involved in the event? What role did they play in the event?
- Interview nurse(s) and other involved staff (each separately) as soon as possible after the event:
- Start by using open-ended questions and allowing involved staff to tell their stories about what happened; • What rationale did they offer for their behavioral choices?
- What was their perception of risk?
- Did they acknowledge and accept responsibility for event fully or partially?
- Were they previously formally counseled (i.e., documented and signed) for same or similar issues?
- Were they experienced and oriented to this unit, patient type, etc.?
- Interview witnesses (each separately) as soon as possible after event:
- Start by using open-ended questions and allowing direct witnesses to tell their stories about what happened;
- Consider degree of agreement or disagreement among witness statements;
- Consider facts and what was actually observed by individuals – do not consider opinions not supported by evidence and corroborating statements.
- Describe the actual event in detail;
- Reconstruct the sequence of events;
- Remember to consider preceding activities that may have impacted the event.
- What usually happens in similar situations? – Describe what involved staff and non-involved staff tell you about such situations – what is their “normal”, current practice? (Make sure they are not just telling you what you want to hear or what policy says!)
- What should have happened? – describe related policies and procedures. (When actual practice varies from policy, you will want to explore why and address this with all staff – maybe policy is out of date or impossible to follow – or maybe all staff have drifted from safe practice!)
WHY did the event occur?
- Identify any and all factors contributing to the event.
- What behavioral choices related to the event did each involved nurse or individual make before, during, and following the event?
- What behavioral choices would a similarly prepared and experienced prudent nurse (or other involved person) have made in the same situation?
- If individual(s) deviated from standards, policies, or procedures, identify rationale for decision to deviate.
- What was happening with other clients and in the environment at the time of the event and immediately prior to the time of the event?
- What was the nurse to client ratio at the time of the event? – Was this a safe, acceptable, manageable ratio?
- Describe any variable factors, such as busy unit, staff call-outs, etc., that influenced workload at the time of the event.
- Was this the usual assignment/unit for the nurse(s) involved in the event?
- What equipment/supplies were involved in the event? – describe equipment/supplies and any unusual aspects, malfunctions, availability issues, etc.
COLLECT AND PROTECT all physical evidence:
- Documentation and records;
- Audit current and past records, if indicted, to identify documentation discrepancies, deficits, and omissions;
- Supplies, equipment, medications, etc.
SUMMARIZE AND DOCUMENT investigation results and conclusions:
- Identify all system issues that need to be corrected.
- Identify all individual practice issues that need to be addressed.
- Identify all known contributing/mitigating/aggravating factors – system and individual
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