This article explores the problems of implementing change in hospital operating theatres, following a series of patient safety incidents known as 'never events' due to their serious nature. Such incidents open a 'window on the system', exposing gaps in an organization's procedures and practices, and highlighting the need for change. However, as documented in other sectors, the recommendations from investigations into the causes of such events are not always implemented. What are the problems? Information was gathered from interviews, from hospital documentation and external reports, and from a theatres team workshop. Analysis of these incidents and the sequence of events that followed demonstrates how post-incident changes were impeded by the mandatory reporting and investigation procedures that were designed to identify and encourage those changes. Institutional regulations and expectations generated a path dependent process, which locked the organization into a narrow range of actions which could be addressed quickly, but which overlooked the wider systemic changes that had been identified as desirable. Post-incident change was caught in an 'investigation trap', sprung by the combination of external demands and internal procedures. Path creation measures for escaping from this trap are suggested, in the interests of effective post-incident change, and improved patient safety.
