Learning from Investigation: Experience with Understanding Healthcare Adverse Events

Thorough, objective investigation of medical adverse events rarely happens due to the complexity of the environment, litigation, risk, and socio-political implications. Special concerns can, and do, undermine investigation depth, breadth, and quality. Healthcare's distinct difference from other high hazard sectors requires a unique approach to adverse event investigation. We report on the initial results of a 15-month pilot program now underway to model a national healthcare investigation team. An example of adverse event investigation and organizational response illustrates these issues.