5. Identifying the care delivery problems 
While working through the incident chronology, care delivery problems will become apparent. These are the things that went wrong in the conduct of the work, in the sense that they deviate from safe practice, and either did, or could have, led to harm. 
Some examples of a care delivery problem include: 

• Not checking a dispensed medicine
• Dispensing the incorrect medicine
• Giving incorrect advice
• Supplying a medicine that is clinically inappropriate.

6. Identifying the contributory factors 
Categories of things that might have contributed to the occurrence of the incident include:

• The patient
• Task and equipment
• Individual members of staff
• The team and communication
• The work environment
• Education and training
• Organisation and management
• The institutional context.

The people investigating the incident should consider which of these – possibly one, possibly a few, possibly many – are linked to the incident under investigation.

7. Making recommendations and developing an action plan
Finally, once it has been determined what has happened, actions to address each factor can be recommended. It is important to identify what needs to be done, and if possible, the priority for doing each of these.