Quality in Healthcare - Critical Incident

Quality in Healthcare

Critical Incident

By Bjørn Andersen, Tom Fagerhaug, and Marti Beltz

The technique of critical incident can aid the search for causes. It is simply about asking the people involved in a process which steps or factors typically cause them the most trouble over a certain period of time. These interviews are typically conducted on the unit or a unit similar to the one involved in an unanticipated event. They are conducted not with people involved in a recent event, but with those who may provide help in understanding the general conditions that may have precipitated an event.

The steps are:

  • Decide on the participants to be included, attempting to cover all departments or functional areas involved in the event.
  • Ask each participant to answer in writing questions like:
    • Which patient care processes are most difficult to handle, and why?
    • What factors create the biggest impediments to maintaining proper patient care?
    • Have you identified gaps in your training?
    • Are there improvements to the process that you have recognized?
    • Do you ever employ “work-arounds” to a process?
  • Collect, sort, and analyze answers based on the frequency of different incidents.
  • Use the most critical incidents as a starting point for the further search for causes of the event.


A private company running an ambulance service was transporting a patient who was experiencing a drug overdose. The patient died en route to the hospital as a result of late arrival by the dispatched ambulance.

The investigation into the event revealed a number of cases where ambulances had arrived late, either at the scene or at the hospital. Since these cases appeared to be the result of a number of different problems, the critical incident technique was used to map which of these constituted the key problems.

The table below shows the critical incident matrix, listing incidents in descending order of frequency of occurrence. This eliminated some possible causes from the inquiries, and others seemed difficult to do much about (outside of influence), but the root cause analysis team used the results to set the direction for the analysis ahead.


last quarter

911 caller gave wrong or no address


Ambulance stuck in heavy traffic


No available ambulance


Driver unable to determine direct route to scene


Other calls took precedence and ambulance was diverted


Road work unknown to driver


Driver did not hear address correctly


Problems with the vehicle


Ambulance involved in accident en route


Openness is a prerequisite
Most tools used in root cause analysis have two things in common:

  • They are best applied by a team of people working together to find the problem’s causes and solve them.
  • To work properly, they require an atmosphere of trust, openness, and honesty that encourages people to divulge important information without fearing consequences.

If a climate of trust is not provided, chances are the root cause analysis will fail to bring to the surface the true nature of the problem or its causes. Creating this climate is everyone’s responsibility, but management clearly possesses the most instruments for achieving it. This is pertinent especially with the critical incident method, as it can bring to light embarrassing situations.

Excerpted from Bjørn Andersen, Tom Fagerhaug, and Marti Beltz, Root Cause Analysis and Improvement in the Healthcare Sector: A Step-by-Step Guide (Milwaukee, WI: ASQ Quality Press, 2010), pages 124-125.

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