Abstract
BackgroundDue to new legislation in 2011 and 2013, the Swedish public healthcare system has undergone change as regards incident reporting and supervision. Focus has turned to learning from adverse events and sharing this learning with actors within the system. The aim of this study was to explore with what underlying safety ontology adverse events in the incident reporting system are investigated.MethodsA content analysis of 90 official and recently completed incident investigations from all six regional supervisory authority offices in Sweden was performed. Data was examined per nature of the investigation, number of targets for intervention, specific final comments in the investigation and the decision from the supervisory authority. A coding scheme was used to identify the organisational level of the targets for intervention.ResultsWith different investigation methods in use, this incident reporting system still seems to contribute to a reproduction of an organisational micro-level understanding of how risks emerge with a focus that operates in the event’s immediate spatial proximity. There are no signs of constructive dialogue on exposed matters between the main actors: the healthcare provider organisation and the supervisory authority. There are strong examples of mistranslation of social infrastructure from other safety-critical organisations. Actors and individuals at the blunt end of the healthcare system adapt to new legislation and organisational change by balancing rhetoric and practice during fulfilment of stated obligations.ConclusionsOur findings support that traditional linear causality construction and traditional norms remain intact despite new legislation and recent organisational change. Through efficient and adapted working procedures by the main actors, this model still brings societal closure of harm and thereby a way to focus on moving on forward.
Highlights
Due to new legislation in 2011 and 2013, the Swedish public healthcare system has undergone change as regards incident reporting and supervision
A Swedish legislative change took place in 2011 with the introduction of the Patient Safety Act [7] and thereafter in 2013 with the creation of a new supervisory authority: the Health and Social Care Inspectorate (HaSCI) [8]. Both legislation and the HaSCI emphasise the responsibility of the healthcare provider organisation (HPO) to learn from adverse events, as well as sharing this learning with others
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]
Summary
Due to new legislation in 2011 and 2013, the Swedish public healthcare system has undergone change as regards incident reporting and supervision. The Institute of Medicine’s report To Err is Human [4] in 2000 pointed out that reporting and subsequent system analysis of adverse events are key in quality and safety Within this discourse, a Swedish legislative change took place in 2011 with the introduction of the Patient Safety Act [7] and thereafter in 2013 with the creation of a new supervisory authority: the Health and Social Care Inspectorate (HaSCI) [8]. A Swedish legislative change took place in 2011 with the introduction of the Patient Safety Act [7] and thereafter in 2013 with the creation of a new supervisory authority: the Health and Social Care Inspectorate (HaSCI) [8] Both legislation and the HaSCI emphasise the responsibility of the healthcare provider organisation (HPO) to learn from adverse events, as well as sharing this learning with others. Despite changes in political governance, Sweden has predominantly continued to have a public healthcare system
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