Critical Incident /System Analysis – A Learning Checklist

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