Employer Event Investigation Guide

Why is event investigation important?

• Identify causes of event – both individual and system issues.
• Prevent similar occurrences.
• Reduce risks to clients and to the organization.

How should event investigation be done?

• Identify a logical, thorough method that works effectively within your setting.
• Approach investigation with an open mind – avoid pre-judging individuals or focusing only on the last person involved in the event!
• Consistently use the same method for evaluating all events.
• Consider ALL contributing factors - both individual and system.
• Avoid considering the extent of harm experienced by the client or others! – near misses are as important as actual harm – keep up your focus on behavioral choices and on risk. Don’t fall into the “no harm – no foul” trap! 
• Don’t look for or accept the easy answer! - Keep asking “WHY” as many as 5 times in a row after each answer you receive in response to your questions! This will make it possible to identify and address the most significant, root causes of the issue as thoroughly as possible.

Use the reliable How? When? Where? Who? What? and Why? questions in a consistent manner to assure that you have examined all elements of and influences on the event.

Answer and document all of the following questions concerning the event in question:

HOW was the event identified or discovered?

WHEN was the event identified or discovered?

• When did the event happen? – At what time?

WHERE did the event occur?

• Describe location and any unusual elements of the environment and location.

WHO has direct knowledge of the event?

• Who discovered or identified the event and how did they do so? – How did the event come to their attention?
• Who reported the event and how did they do so? – How did the event come to their attention?
• Who was directly involved in the event? 
• nurse(s)
• physicians
• other staff (e.g., nurse aides, therapists, secretaries)
• client(s)
• family members/visitors
• How were each of the individuals involved in the event? What role did they play in the event?
• Interview nurse(s) and other involved staff (each separately) as soon as possible after the event:
• Start by using open-ended questions and allowing involved staff to tell their stories about what happened; 
• What rationale did they offer for their behavioral choices?
• What was their perception of risk?
• Did they acknowledge and accept responsibility for event fully or partially?
• Were they previously formally counseled (i.e., documented and signed) for same or similar issues?
• Were they experienced and oriented to this unit, patient type, etc.?
• Interview witnesses (each separately) as soon as possible after event:
• Start by using open-ended questions and allowing direct witnesses to tell their stories about what happened;
• Consider degree of agreement or disagreement among witness statements;
• Consider facts and what was actually observed by individuals – do not consider opinions not supported by evidence and corroborating statements.

WHAT happened? 

• Describe the actual event in detail;
• Reconstruct the sequence of events;
• Remember to consider preceding activities that may have impacted the event.
  
• What usually happens in similar situations? – Describe what involved staff and non-involved staff tell you about such situations – what is their “normal”, current practice? (Make sure they are not just telling you what you want to hear or what policy says!)
• What should have happened? – describe related policies and procedures. (When actual practice varies from policy, you will want to explore why and address this with all staff – maybe policy is out of date or impossible to follow – or maybe all staff have drifted from safe practice!)

WHY did the event occur?

• Identify any and all factors contributing to the event.
• What behavioral choices related to the event did each involved nurse or individual make before, during, and following the event?
• What behavioral choices would a similarly prepared and experienced prudent nurse (or other involved person) have made in the same situation?
• If individual(s) deviated from standards, policies, or procedures, identify rationale for decision to deviate.
• What was happening with other clients and in the environment at the time of the event and immediately prior to the time of the event?
• What was the nurse to client ratio at the time of the event? – Was this a safe, acceptable, manageable ratio?
• Describe any variable factors, such as busy unit, staff call-outs, etc., that influenced workload at the time of the event.
• Was this the usual assignment/unit for the nurse(s) involved in the event?
• What equipment/supplies were involved in the event? – describe equipment/supplies and any unusual aspects, malfunctions, availability issues, etc.

COLLECT AND PROTECT all physical evidence: 

• Documentation and records;
• Audit current and past records, if indicted, to identify documentation discrepancies, deficits, and omissions;
• Supplies, equipment, medications, etc.

SUMMARIZE AND DOCUMENT investigation results and conclusions:

• Identify all system issues that need to be corrected.
• Identify all individual practice issues that need to be addressed.
• Identify all known contributing/mitigating/aggravating factors – system and individual.

For nurses' practice issues, the next step is to complete the NCBON Complaint Evaluation Tool (CET).  The NCBON CET is designed for use in evaluating clinical practice events or issues involving Registered Nurses and Licensed Practical Nurses, all of whom are regulated by the NCBON.  North Carolina is a "mandatory" reporting state, meaning that any suspected violations of the Nursing Practice Act must be reported to the Board.  The NCBON CET provides a "Just Culture" framework through which nursing leaders/employers can evaluate nursing clinical practice events.  Use of the NCBON CET provides a standard by which the employer and Board can work collaboratively and communicate openly.  The CET directs nursing leaders/employers to console nurses for Human Errors; to consult with Board staff to determine the reportability of At Risk Behaviors; and to submit a formal report/complaint to the Board for Reckless Behaviors.

Some organizations may have training and experience in the use of the "Just Culture" Algorithm developed by David Marx and Outcome Engineering.  If this is the case, participants will first evaluate the event using the "Just Culture" Algorithm and will then use the NCBON CET to determine the reportability of the event to the Board.

NOTE: Confidentiality, fraud, theft, drug abuse, impairment on duty, drug diversion, boundary issues, sexual misconduct, and mental/physical impairment are not appropriate for evaluation using the NCBON CET.  These events/issues are conduct and health-related issues, not practice incidents or events, and MUST be reported to the NC Board of Nursing.