Step 1 - Gather information, including what, when, how and why the adverse event occurred. What were the immediate and root causes?
Step 2 - Analysis of information, involves examining all the facts, determining what happened and why. All the detailed information gathered should be assembled and examined to identify what information is relevant and what information is missing.
Step 3 - Identifying risk control measures. The methodical approach adopted in the analysis stage will enable failings and possible solutions to be identified. These solutions need to be systematically evaluated and considered for implementation.
Step 4 - Action Plan and Implementation. At this stage, senior management, who have the authority to make decisions and act on the recommendations of the investigation team, should be involved. An action pan for the implementation of additional risk control measures is the desired outcome of a thorough investigation.