Step 4: Investigation
Incidents are reviewed and investigated to identify opportunities for improving safety: the level of the investigation relates to the ISR.
Click on the ISR numbers to see how incidents are investigated within VHIMS.
ISR 1
ISR 1 incidents will receive a detailed and thorough investigation using RCA methodology and should be led by a trained facilitator.
ISR 2
ISR 2 incidents are to be reviewed using in-depth case review methodology and should be led by a senior manager. Analysis of ISR 2 incidents may identify system issues that will lead to service improvement projects.
ISR 3 and ISR 4
ISR 3 and ISR 4 incidents will require review of aggregate data at the local level. Some individual cases may require additional review by the department manager or their delegate.
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