How incident reporting can stimulate social and participative learning: a mixed-methods study

D (David) de Kam, JH (Josje) Kok, KJ (Kor) Grit, IP (Ian) Leistikow, Maurice Vlemminx, RA (Roland) Bal

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tIncident reporting systems (IRSs) have been widely adopted in healthcare, calling for the investigationof serious incidents to understand what causes patient harm. In this article, we study how the Dutch IRScontributed to social and participative learning from incidents. We integrate quantitative and qualitativedata in a mixed-methods design. Between 1 July 2013 and 31 March 2019, Dutch hospitals reported andinvestigated 4667 incidents. Healthcare inspectors scored all investigations to assess hospitals’ learningprocess following incidents. We analysed if and on what aspects hospitals improved over time. Addition-ally, we draw from semi-structured interviews with incident investigators, quality managers, healthcareinspectors and healthcare professionals. Healthcare inspectors score incident investigation reports better over time, suggesting that hospitals conduct better investigations or have become adept at writing reports in line with inspectors’ expectations. Our qualitative data suggests the IRS contributed to practices that support social and participative learning—the professionalisation of incident investigation teams, the increased involvement of patients and families in investigations—and practices that do not—not linking learning from the investigation teams to that of professionals, not consistently monitoring the recommendations that investigations identify. The IRS both hits and misses the mark. We learned that IRSs need to be responsive to the (developing) capabilities of healthcare providers to investigate and learn from incidents, if the IRS is to stimulate social and participative learning from incidents.
Original languageEnglish
Pages (from-to)834-841
Number of pages8
JournalHealth Policy
Issue number8
Publication statusPublished - Aug 2020

Bibliographical note

The research projects reported on here were conducted within and supported by the Dutch Academic Collaborative Centre of Supervision, a research collaborative that pairs up the Inspectorate with four research institutes with the aim to study and enhance the effectivity of the Inspectorate’s regulatory practices. The first project was not funded. The second project was supported by ZonMw, the Dutch organisation for Health Research and Development, project number 516004604.

Research programs

  • EMC NIHES-05-63-02 Quality


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