Analysis of results from event investigations in industrial and patient safety contexts.
The primary purpose of incident reporting and analysis is to propose safety reforms. This study reviewed three sets of event investigations (one from industrial companies and two from hospitals) using two methods of investigation (in-depth or root cause analysis). In-depth analysis resulted in more suggestions for reform targeted at the federal, regional, health system, or department level. Root cause analysis resulted in suggestions at the department or ward level. The authors conclude there is room for improvement in in the management and performance of event investigations in the healthcare sector.