Does Your Organization Follow Best Practices for Investigating a Harm Event?

May 18, 2021

Investigating a harm event rapidly and thoroughly allows for earlier insight into the contributory causes and identification of preventive measures to avoid recurrence. Responding quickly and effectively to harm events is what facilitates early evaluation, open communication, preservation of facts, learning, and possibly resolution and healing.

Event investigation best practices

A 72-year-old patient hospitalized on a medical unit fell during the overnight hours. The nightshift team got the patient back into bed, called the on-call physician and reported the patient was not complaining of any injuries. The on-call physician said he would let the attending physician examine the patient during rounds the next morning.

Later that morning, the patient complained of a sore right hip. The attending ordered X-rays that showed a fracture of the hip. The patient was referred to an orthopedic surgeon who surgically repaired the hip later that same day. One year later, the patient filed a malpractice claim against the hospital alleging failure to ensure safety from a fall. This was the first indication to risk management and administration that a harm event had occurred. An accurate investigation was hard to complete as there was little documentation about what happened that night.

Event investigation should begin within 72 hours of an identified harm event. The most important initial response to an event is to attend to the person who was injured and take action to stop any further harm. Next steps include:

  • Prioritize ongoing care
  • Notify treating clinician(s) and other involved care team members
  • Report the event through the organization’s event reporting system to trigger notification to leadership and risk management
  • Perform a preliminary review of the event and secure the scene, as well as any involved equipment
  • Provide emotional support for the patient/resident and family, as well as the involved clinicians and team members
  • Initiate an in-depth investigation to identify causal and contributing factors to the event
  • Develop targeted solutions to improve vulnerable care processes and an action plan to communicate and spread process changes

A thorough investigation should uncover what happened, why it happened and assist in identification of measures to avoid recurrence.

“Advance planning for investigative processes will ensure readiness to respond in those crucial first hours and days. It will also ensure processes are centered on investigating facts, preserving evidence and identifying process improvement opportunities.”

Heather Meyer, Senior Risk Consultant at Constellation®
Learning after a harm event

Rapidly investigating a harm event allows for organizational learning by identifying causal factors and targeted solutions that can help prevent future events. Share lessons learned and safety stories within the organization through executive summary reports, team huddles, unit/department meetings and organizational communication forums. While each harm event may be unique, there are common fundamentals to help your organization improve, learn and heal.

Doing better after harm events: The HEAL® Prepare Toolkit

Our HEAL Prepare Toolkit helps your organization prepare for harm events so you can respond quickly and effectively. The Toolkit includes a unit on event response that contains assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) patient communication, and (4) moving forward. Sign in to to access the HEAL Prepare Toolkit found in Risk Resources.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.


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