695 © Springer International Publishing Switzerland 2017 J.A. Sanchez et al. (eds.), Surgical Patient Care, DOI 10.1007/978-3-319-44010-1_41 How Not to Run an Incident Investigation Bryce R. Cassin and Paul Barach B.R. Cassin, RN, BA Hons (Class 1) (*) School of Nursing and Midwifery, Hawkesbury Campus, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia e-mail: b.cassin@westernsydney.edu.au P. Barach, BSc, MD, MPH Clinical Professor, Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Wayne State University School of Medicine, 5057 Woodward Avenue, Suite 13001, Detroit, MI 48202, USA e-mail: Pbarach@gmail.com 41 “If you don’t inquire in a way that respects the intelligence of the other person, you probably won’t find many insights.” —Gary Klein, Seeing What Others Don’t, 2013 Don’t Let the Investigation Get in the Way of Learning from People Incident investigation is an integral feature of perioperative surgical safety programs and is likely to be fundamental in directing future initia- tives. Advances in clinical practice and biomedi- cal technology make the challenge of doing effective incident investigation more complex and nuanced. There is a palpable distance between the stable incident investigation activi- ties of quality and safety departments and the continually evolving scope of surgical practice necessitating increasingly risky and complex procedures, requiring clear communication across clinical disciplines, and ongoing adjust- ment to the subtle changes in workplace conditions. Incident investigation should not be a remote activity of senior management disconnected from everyday practice in the perioperative set- ting but a functional tool for discovering fresh insights about the challenging aspects of the local clinical workplace in context [1]. Local experi- ence and expertise are important factors in shap- ing a culture of good clinical judgment and decision-making [2]. However, clinicians remain ambivalent about incident investigation pro- cesses and tend to find more value in the informal debriefing conversations that start up after an adverse event across the organization. Perhaps the establishment of local review meetings and departmental debriefings is the most vital aspect of any incident investigation process. A good and timely debrief shifts the conversation from a ret- rospective search for isolated causes to a pro- spective exploration of patterns and cues in the local clinical workplace that emerge from every- day activity over time [3–6]. Nonetheless, it is commonplace for hospitals and health service providers to use structured methods for the analysis of adverse events, the determination of contributing factors, and the implementation of corrective actions to improve the safety and performance of clinical systems (e.g., root cause analysis in combination with human factors engineering). Incident investiga- tion typically involves a broad range of tech- niques for gathering and arranging the facts that relate to adverse events into a report that catego- rizes areas of breakdown and vulnerability in the interactions within a clinical micro-system [7, 8]. Investigation methods have become systematized