An ICU team conducts a structured mortality and morbidity (M&M) review of a patient who died unexpectedly. The review identifies a system failure wher...

Question

An ICU team conducts a structured mortality and morbidity (M&M) review of a patient who died unexpectedly. The review identifies a system failure where a critical laboratory result was not communicated to the medical team for 6 hours. What patient safety framework should be used to investigate this incident?

Accepted Answer

Conduct a systems-based investigation using the Patient Safety Incident Response Framework (PSIRF), identifying contributing factors, system vulnerabilities, and implementing learning to prevent recurrence

Answer

Ignore the incident as the patient has died

Answer

Blame the individual who failed to communicate the result

Answer

Only investigate if a formal complaint is received from the family

Answer

Report to the police immediately

uk-fficm MCQ (SBA): Patient Safety Investigation