Once an NCE has been accurately identified, the occurrence must be investigated. As early as possible, the risk involved in the event is considered. The events that led up to the NCE should be examined. Available evidence that supports all decisions made during the process in question is collected and collated. Was patient care compromised? How frequently does this type of event occur? How severe were the consequences? Determine in which part(s) of the total testing process the failure occurred.
The investigation should focus on the processes involved in the situation, rather than placing blame on individuals; perform this step as objectively as possible. Some helpful hints include:
- Interview staff in a friendly, non-accusatory manner
- A personal agenda should not be included in any interviews or questions
- Do not stop at 'human error" or "lack of training" when looking for causes of the incident
- Explain the process to the persons being interviewed
- Be sure to actively listen
