Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews

Lan, Melissa F., Weatherby, Hilary, Chimonides, Elisa, Chartier, Lucas B. and Pozzobon, Laura D. 2025. Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews. Healthcare Management Forum 10.1177/08404704251343260

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Abstract

Our Canadian multi-site academic health sciences centre uses a standardized process to review critical patient safety incidents and develop recommendations to prevent incident reoccurrence. We recognized an opportunity to enhance recommendation development by integrating the Hierarchy of Intervention Effectiveness (HIE), a human factors framework, into the incident review process. This project aimed to increase the proportion of system-focused recommendations from critical incident reviews from 16 to 30% over 16 months. A multi-intervention strategy included (1) standardizing the incident analysis review template; (2) earmarking time for recommendation development during reviews; (3) providing participants with just-in-time education and tools; and (4) initiating HIE-based recommendation classification during incident reviews. Statistical process control p-Chart analysis showed an increase in system-focused recommendations from 16 to 30% over 16 months. The HIE promotes system-level change to prevent critical incidents, which other organizations may benefit from incorporating in their patient safety reviews.

Item Type:	Article
Date Type:	Published Online
Status:	In Press
Schools:	Schools > Medicine
Publisher:	SAGE Publications
ISSN:	0840-4704
Date of First Compliant Deposit:	19 June 2025
Last Modified:	19 Jun 2025 14:00
URI:	https://orca.cardiff.ac.uk/id/eprint/179207

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