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15Investigation and
Learning from Deaths in
Community/Primary Care
Extending medical examiner scrutiny to
noncanonical deaths
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What is investigation and learning from?
Investigation and learning from refers to the process of examining incidents or events to understand their causes, impact, and potential lessons to improve future practices.
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Organizations, teams, or individuals involved in incidents that warrant an analysis and learning process are required to file investigation and learning reports.
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To fill out an investigation and learning report, one should gather information about the incident, document the findings, summarize lessons learned, and propose recommendations for improvement.
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The purpose is to identify the root causes of incidents, enhance safety protocols, improve processes, and prevent future occurrences.
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Information that must be reported includes a detailed account of the incident, involved parties, timeline, root cause analysis, lessons learned, and recommendations.
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