On safety ontology: a cross-section analysis of incident investigations in a public healthcare system

Abstract

The content analysis aimed to identify, examine and code all targets for intervention from all incident investigations and short internal reports, together with the investigations’ plans for follow-up or other intentions. [...]data was examined per (a) the nature of the internal incident investigation, (b) the number of targets for intervention from the internal incident investigations, (c) attached final comments from the CMO to the supervisory authority regarding the adverse event and (d) the supervisory authority decision in the external incident investigation. Arguments can also be made that the healthcare system has implemented a model where a certain ‘local technical fix’ is the solution to whatever incident that occurs [20] and that the incident report processing of large volumes of adverse events perhaps is inadequate [21]. Since this study shows that usage or not of provided methodological support for internal incident investigations does not alter the target for intervention after an adverse event, Hollnagel’s two principles WYLFIWYF (‘What You Look For Is What You Find’) and WYFIWYF (‘What You Find Is What You Fix’) seem highly applicable [22, 23]. [...]our data showed that in a vast majority of reported adverse events, the same investigatory approach was observed in all the regional supervisory authority offices; the case was closed after the first reviewing of the internal incident investigation. [...]focusing on all the guiding questions together, we argue that the results in this study picture the consequences that can emerge in a system with mandatory incident investigations in a resource-constrained environment, such as the Swedish public healthcare system.