Process Checklist for Guideline for the Systems Analysis Investigation of Incidents

Guideline for the Systems Analysis Investigation of Incidents
The purpose of the check-list is to act as an aide memoir to managers and staff to assist them to ensure compliance with the HSE Guideline for the Systems Analysis Investigation of Incidents. The check-list must always be used in conjunction with HSE Guideline for the Systems Analysis Investigation of Incidents. References to the relevant sections of the guideline have been included in the check-list. / Refer to the relevant Guideline Section(s) for guidance on each stage of the process. / Tick as Appropriate
1 / Commissioning and establishing a Systems Analysis Investigation / 7.1 / Yes / No / N/A
1.1 / The Senior Accountable Officer in conjunction with the Safety Incident Management Team will commission an investigation and establish an appropriate Investigation Team within 2 working days following notification of the incident to the senior accountable officer / 7.1.1
1.2 / Where appropriate link people are identified to meet and/or communicate with all individuals involved in the investigation process / 7.1.1
1.3 / Terms of Reference are developed by the Investigation Commissioner / 7.1.2
1.4 / Terms of Reference developed are as is set out in the Safety Management Policy (2014) / 7.1.2
1.5 / Where other investigations are being carried out on the incident, the Investigation Commissioner ensures/ facilitates appropriate communications and linkages between the various investigation bodies / 7.1.4
1.6 / Relevant consent (to access records) is obtained by the Investigation Commissioner / 7.2
1.7 / If consent is not received, there is evidence of an appropriate decision making process by the Investigation Commissioner to determine if and how the investigation will proceed / 7.2
2 / Step 1: Organise the Investigation and Gather the Data / Guidance Section / Yes / No / N/A
2.3 / All pertinent information in relation to the incident is identified and gathered by the Investigation Team / 7.2.2
2.4 / A draft chronology of events based on the review of information received is developed by the Investigation Team prior to conduction of interviews / 7.2.3
2.5 / The Investigation plans and conducts interviews with all individuals relevant to the incident under investigation / 7.2.4 – 7.2.5
2.6 / A back-up file related to the investigation is established and maintained. / 7.8.3
3 / Step 2: Complete the Incident Chronology / Guidance Section / Yes / No / N/A
3.1 / The investigation Team completes a detailed chronology based on the information from the records, interviews etc. that demonstrates what happened and when in relation to the incident / 7.3
4 / Step 3: Identify Key Causal Findings and Incidental Findings / Guidance Section / Yes / No / N/A
4.1 / If the requirement for external expert is identified by the Investigation Team it is sourced as outlined in the Guideline for Systems Analysis Investigation of Incidents / 7.1.5
4.2 / All Key Causal Factors are identified by the Investigation Team / 7.4
4.3 / Where no Key Causal Factors are identified, the report explains how the Investigation Team reaches the conclusion that there are no Key Causal Factors / 7.4
4.4 / All Incidental Findings are identified by the Investigation Team / 7.4
5 / Step 4: Identify the Contributory Factors related to the Key Causal Findings and the Incidental Findings / Guidance Section / Yes / No / N/A
5.1 / The Contributory Factors Framework is used to analyse each Key Causal Factor to determine the Contributory Factors/ causes of the incident / 7.5
5.2 / Incidental Findings are adequately analysed and explained using the Contributory Factors Framework where appropriate / 7.5
6 / Step 5: Make Recommendations that will Reduce Risk and Improve Quality and Safety / Guidance Section / Yes / No / N/A
6.1 / Recommendations are made by the Investigation Team to improve the quality and safety of services where required / 7.6.1
6.2 / Recommendations are clearly linked to the Key Causal Factor and Contributory Factors identified / 7.6.1
6.3 / Recommendations are SMART / 7.6.1
6.4 / Recommendations are developed using the hierarchy of preferred control measures / 7.6.2
7 / Step 6: Write the Investigation Report / Guidance Section / Yes / No / N/A
7.1 / An anonymised draft investigation report is developed by the Investigation Team using the report template contained in the Guideline for Systems Analysis Investigation of Incidents / 7.7
7.2 / Fair Procedures are fully implemented in the development and finalisation of the investigation report as set out in the Guideline for Systems Analysis Investigation of Incidents / 7.7
7.3 / The Investigation Team presents the final investigation report to the Investigation Commissioner / 7.7
7.4 / The Investigation Commissioner ensures the circulation, assessment, monitoring and implementation of the recommendations of the report and the local and national sharing of learning from the investigation as appropriate. / 7.7

Process Checklist for the HSE Guidelines for the Systems Analysis Investigation of Incidents, NIMLT F015, Revision 1, August 2016, Page 1 of 2