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Systemic incident analysis with PRISMA

Learning from incidents

Incidents are a chance to learn something and thereby prevent new incidents. In the medical world, PRISMA is a well-known method (and according to Oxford a reliable one) to analyse them. Below is an example of the visualisation of a case.

_Prisma

Also useful in tech

This method can also be useful within tech companies.

Chronological reconstruction

An investigation team makes a chronological reconstruction, based on the available data and interviews.

Cause tree

The team records the logical relation between the incident and the root causes in a cause tree. The root causes can directly serve as input for recommendations for improvement.

Finding patterns

With the help of a classification model, the results of multiple analyses can be used to discover patterns. This makes it possible to substantiate improvements across the whole organisation.