Critical Incidents and Performance Improvement

Robert Johnson - Monday, June 14, 2010

When the focus of a critical incident is on the person who is identified with, or as the problem, there is a tendency to try to fix the person instead of resolving the problem.

Causes of Critical Incidents: Three Categories

Physical Causes are the tangible causes of failures.

The wheel bearing broke

Human Causes trigger a physical cause of failure. These could be errors of commission (we did something we should not do) or omission (we did not do something we should have done).

 “The wheel bearing was not properly installed”

Organizational Causes originate within the operational systems in which people function.

 “There is no system in place to ensure that the lead mechanic’s duties are performed correctly by his assistant when he is on annual leave

The most effective and sustainable solutions are those that address the latent or organizational/systemic causes of problems.  Why? The root causes of all problems are systemic. Without addressing the root of “the problem”, it will continue to appear through various visible symptoms related to “human” failures/mistakes.

Sequence of Causation:

  • The cause of patient death was self-induced drug intoxication (Physical)
  •  The drugs were accessible to the patient due to a mistake by a nurse in securing medication (Human)
  •  The nurse did not secure the medication because she had worked three consecutive days of double shifts, and was extremely fatigued. (Human)
  •  The nurse worked three consecutive double shifts because there was a staffing shortage due to a hiring freeze caused by a decrease in hospital revenue. (Organizational)
  •  Hospital revenue was down because of poor strategic planning. (Organizational)
  •  Strategic planning was not adequate because it was not a priority of the hospital’s director and board. (Organizational)

Since all incidents have physical and human components, it is necessary to identify errors of omission or commission that were committed by individuals that contributed to the ensuing failure. Employees are typically reluctance to explore the human components due to fear of being identified as the “root cause” of the incident. Organizational cultures that reinforce this dynamic attempt to prevent recurrence of incidents through disciplinary or training actions, rather than an analysis of the systemic organizational processed related to the event. In family systems theory, this type of approach is referred to as focusing on the “identified patient”, rather than the causes and conditions within the family structure that is producing the symptomatic behavior.

Organizational Culture Supportive of Systemic Solutions

  • Emphasizes the need for identification of a broad range of causes contributing to problems.
  • Distinguishes between human resource personnel actions and the investigation of systemic causes when engaged in problem-solving.
  • Ensures that both causes and solutions have strong factual supporting evidence.
  • Follows a structured (and disciplined) approach to problem-solving.

Five Tips for Achieving Organizational Solutions

  • Clearly define events that constitute critical incidents.
  • Implement a sequential process for reporting critical incidents that is supported through staff education, training, easy to understand reporting guidelines, and informative reporting formats.
  • Conduct a critical incident investigation process that provides a comprehensive and factual account of all factors related to the incident.
  • Initiate a root cause analysis process that utilizes proven methodology to identify the organizational factors related to the actual incident.
  •  Complete a structured action-planning process that addresses the organizational conditions identified and leads to a significant reduction of further incidents.

 You cannot change the human condition, only the conditions in which humans exist