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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?
    • Nurse(s)
    • Physicians
    • Other Staff (e.g., Nurse Aides, Therapists, Secretaries) 
    • Client(s)
    • 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.

WHAT happened?

  • 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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Last Changed 13-Aug-2018

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