Critical Incident /System Analysis – A Learning Checklist
What Happened/Focus of Investigation
Brief description of incident – just the facts:
Margin for Error
Patient Factors
- Age/Sex?
- Comorbidities?
- Medications/Allergies?
- Diagnosis/Prognosis?
- Personality Factors?
- Social/Cultural Factors?
- Anything Else?
Task Factors
- Routine/Emergency?
- Simple/Complex?
- Level Of Skill Required?
- Time Constraints?
- Fixed Sequence Essential?
- Risks:
- Chances of failure?
- Impact of failure?
- Complications?
- Anything Else?
Active Error
Individual Factors
- Position/Rank?
- Education/Training?
- Experience/Intuition?
- Fatigue/Stressors?
- Physical/Mental Health?
- Task Saturation/Overload?
- Anything Else?
Latent Errors and Conditions
Team Factors
- Regular Team ?
- Defined Roles?
- Authority Gradients?
- Communication Good/Bad?
- Team Culture/Morale?
- Regular Drills?
- Briefings/debriefings?
- Anything Else?
Workplace Factors
- Environment
- Physical Layout?
- Access/Isolation?
- Lighting/Temp/Noise?
- Equipment
- Appropriate/Modern?
- Design?
- Maintained/Neglected?
- Protocols/Policies
- Available/Workable?
- Standard operating procedures?
- Checklists?
- Inservices/Briefings?
- Manpower
- Rosters/Overtime?
- Remuneration?
- Multitasking?
- Senior Help Available?
- Anything Else?
Organisational Factors
- Staffing Patterns?
- Regulars/Trainees/Locums?
- Paging/Telephone System?
- Inform Design/Records?
- Quality Assurance Program?
- Organisational Culture?
- Clerical/Administrative?
- Legislation?
- Anything Else?
Summary and Comments
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