Analysis of Learning from IncidentsProcesses in Swedish and DutchHealthcare Systems : A Mixed Methods Study for Cross-Border Learning ; Analys av lärande från incidentprocesser i svenska och nederländskasjukvårdssystem : En mixed methods studie för gränsöverskridande lärande
Many healthcare organisations face repetitive incidents because organisations tend to fail to learn from the past. Learning from incidents (LFI) in healthcare is a process through which healthcare professionals and the organisation as a whole seek to understand adverse events that have taken place. The LFI process consists of five main steps: data acquisition, investigation and analysis, planning interventions, implementing interventions, and evaluations. In order to reduce the reoccurrence of incidents, it is important that LFI processes are improved. As a prerequisite, it is necessary to gai... Mehr ...
Many healthcare organisations face repetitive incidents because organisations tend to fail to learn from the past. Learning from incidents (LFI) in healthcare is a process through which healthcare professionals and the organisation as a whole seek to understand adverse events that have taken place. The LFI process consists of five main steps: data acquisition, investigation and analysis, planning interventions, implementing interventions, and evaluations. In order to reduce the reoccurrence of incidents, it is important that LFI processes are improved. As a prerequisite, it is necessary to gain insight into the steps of the LFI process to identify hindrances (bottlenecks) and mitigate them. This thesis is a broad comparative study of the LFI processes in Dutch and Swedish healthcare systems. Cross-border comparisons between LFI systems can support mutual learning, and consequently lead to improvements of healthcare organisations’ learning processes. The study consists of an analysis of Swedish and Dutch legislation, national healthcare inspectorates, and hospitals’ learning from incidents processes. Legislation was analysed through a (legal) documentation study. Healthcare inspectorates’ practices in LFI were analysed by a combination of documentation studies, and by conducting interviews with one Dutch inspector, one Swedish inspector, and one Swedish development strategist. For analysis of hospitals’ LFI processes, a questionnaire and interview study with fourteen Dutch and eleven Swedish hospitals were conducted. Analysis of these processes was done at the hand of a number of quality statements developed based on a literature study. The main differences between how the two countries’ learn from incidents are in data acquisition, and investigation and analysis. The Netherlands have various reporting systems, as well as diversity in incident investigation methods. Sweden has more uniformity in these matters. Moreover, Sweden has a national system for sharing lessons learned between hospitals, which can benefit ...