Tools for the investigation of adverse events: scoping review.
Lucas Rodrigo Garcia de Mello, Barbara Pompeu Christovam, Ana Paula Amorim Moreira and 3 others
PMID 35724262WHAT IT FOUND
This scoping review maps tools for investigating patient adverse events.
It highlights that root cause analysis is widely used but often inconsistent, relying too heavily on interviews. The authors suggest combining interviews with observation techniques and accountability matrices to better identify systemic failures.
Key findings
01The review identified 31 studies describing various tools for investigating adverse events, with a predominance of qualitative methods and expert consensus.
02Root cause analysis (RCA) is the most common framework, but its application varies widely between institutions due to a lack of standardization and reliability among evaluators.
03Interviews are the most frequently used data collection method, but the review notes they are limited because employees may report what should have happened rather than what actually occurred.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The review included a mix of study types, including gray literature and expert consensus, which may vary in quality. There is a lack of high-level evidence (such as RCTs or systematic reviews) assessing the effectiveness of these investigation tools. The search was limited to studies available in full text, which may have excluded some relevant but inaccessible reports.
Declared interests
The study was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). No other conflicts of interest are reported.
The easy way to misread this
Do not interpret this review as evidence that these investigation tools have been proven to reduce adverse events. The authors explicitly state that there are no randomized trials or meta-analyses assessing the effectiveness of these tools, only a mapping of their existence and usage.