A database tool for centralized analysis of untoward health care events

Most risk management systems are designed to identify the "who," "what," and "where" of untoward health care events. This approach fails to identify the root causes, the "how" and "why." These are likely to appear only when aggregated around a high risk "what"; they are actually more prevalent than the data would indicate. This paper describes a system that focuses on the early identification of trends and patterns in the "how" and "why" of untoward events. Awareness of these can provide a basis for improved clinical practice and professional risk avoidance, before intersection with a high risk "what" produces an untoward medical event.