How incident reporting systems can stimulate social and participative learning: A mixed-methods study.

Area of Science:

• Healthcare quality and safety
• Patient safety research
• Organizational learning in healthcare

Background:

• Incident reporting systems (IRSs) are crucial for investigating patient harm.
• Understanding how IRSs facilitate learning from serious incidents is essential for healthcare improvement.

Purpose of the Study:

• To evaluate the Dutch IRS's contribution to social and participative learning from incidents.
• To assess improvements in hospital incident investigations over time.

Main Methods:

• Mixed-methods design integrating quantitative and qualitative data.
• Analysis of 4667 reported incidents (July 2013-March 2019).
• Scoring of investigations by healthcare inspectors and semi-structured interviews.

Main Results:

• Hospitals showed improvement in investigation report quality over time.
• IRS enhanced professionalization of investigation teams and patient/family involvement.
• Gaps identified in linking team learning to professional practice and monitoring recommendations.

Conclusions:

• The Dutch IRS partially succeeds in promoting social and participative learning.
• IRS effectiveness depends on responsiveness to healthcare providers' evolving investigation and learning capabilities.
• Further development needed to fully leverage IRS for learning from incidents.