Educational Material

[Article] Incident and adverse event investigation: Approaches and benefits of clustered notification analysis

Incident and adverse event investigation is a crucial process for identifying and understanding failures in healthcare systems that affect patient safety. Incidents are unforeseen situations that occur during patient care, which may or may not result in harm, while adverse events are incidents that cause harm to the patient’s health. The investigation aims at revealing the causes of these incidents and implementing corrective and preventive measures, promoting a safety culture and learning in healthcare institutions.

The relevance of investigating incidents and adverse events is related to the need to understand failures at a given stage of the patient care process. This makes it possible not only to correct errors but also to prevent them from happening again. Analyzing these events helps identify factors that contributed for them to happen, such as communication-related issues, gaps in protocols, and equipment failures that may be the true responsible behind the incidents.

Benefits of cluster research

Incident and adverse event cluster research focus on analyzing similar events that occurred within a specific period or context. Rather than examining an incident separately, the clustered approach looks for patterns and common causes across multiple incidents, bringing material benefits to improving patient safety. Here are some examples:

• Identification of recurring patterns: One of the main benefits of cluster research is the ability to identify trends that would not be noticeable in separate analyses. When similar incidents occur repeatedly, cluster analysis can reveal systemic failures that affect multiple parts of the healthcare process, such as protocol issues or insufficient training.
• Optimization of resources: Analyzing multiple clustered adverse events is more efficient considering it avoids the need to investigate each one separately. This saves time and resources, allowing teams to focus on implementing comprehensive and effective solutions.

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