Once an NCE has been accurately identified, the occurrence must be investigated. Examine the events that led up to the NCE. Collect any evidence available that supports all decisions made during the process in question. As early as possible, consider the risk involved in the event. 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 happened.
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
- Do not have a personal agenda
- Do not stop at 'human error" or "lack of training"
- Explain the process to those being interviewed
- Be sure to listen actively
