[Incident analyses at Sørlandet Hospital 2020–22]

Incident analyses are used at Sørlandet Hospital to identify root causes of selected adverse events and to propose measures to prevent recurrence. The aim of the study was to identify the most common root causes and proposed measures in incident analyses conducted at Sørlandet Hospital in Norway during the period 2020-22.

Data were retrieved from the electronic quality management system at Sørlandet Hospital. Two doctors and one nurse with experience in incident analysis reviewed the events and the proposed measures. The Norwegian Directorate of Health's handbook for incident analysis was used to categorise root causes and to assess the anticipated effect of the proposed improvement measures on the risk of recurrence.

A total of 35 incident analyses were included. Most events were serious, with 16 patient deaths and 12 cases of severe injuries. Three or more hospital departments were involved in 28 of the events. The most common causes were failures in communication and information transfer, followed by shortcomings in the care environment and organisation. In 34 of the 35 events, measures with an anticipated limited effect on the risk of recurrence were proposed, while measures considered effective and very effective were proposed in 22 and 3 events, respectively.

Failures in communication between healthcare personnel were the most common cause of adverse events that led to incident analyses at Sørlandet Hospital. Measures considered to have a very high potential to prevent recurrence were proposed in just three events.