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

Wrigstad, Jonas LU ; Bergström, Johan LU and Gustafson, Pelle LU (2017) In Safety in Health 3(13).
Abstract
Background:
Due 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.

Methods:
A content analysis of 90 official and recently completed incident investigations from all six regionalsupervisory authority offices in Sweden was performed. Data was examined per nature of the investigation, numberof targets for intervention, specific final comments in the investigation and the decision from the... (More)
Background:
Due 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.

Methods:
A content analysis of 90 official and recently completed incident investigations from all six regionalsupervisory authority offices in Sweden was performed. Data was examined per nature of the investigation, numberof 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.

Results:
With different investigation methods in use, this incident reporting system still seems to contribute to are production of an organisational micro-level understanding of how risks emerge with a focus that operates inthe 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 endof the healthcare system adapt to new legislation and organisational change by balancing rhetoric and practiceduring fulfilment of stated obligations.

Conclusions:
Our findings support that traditional linear causality construction and traditional norms remain intactdespite new legislation and recent organisational change. Through efficient and adapted working procedures bythe main actors, this model still brings societal closure of harm and thereby a way to focus on moving on forward (Less)
Please use this url to cite or link to this publication:
author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Adverse event, Incident investigation, Healthcare, Legislation, Ontology
in
Safety in Health
volume
3
issue
13
publisher
BioMed Central
ISSN
2056-5917
DOI
10.1186/s40886-017-0064-7
language
English
LU publication?
yes
id
469a7338-ef21-4f56-a4fc-90b560abb1e3
date added to LUP
2017-10-19 12:58:56
date last changed
2017-11-06 12:09:57
@article{469a7338-ef21-4f56-a4fc-90b560abb1e3,
  abstract     = {Background:<br/>Due 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.<br/><br/>Methods:<br/>A content analysis of 90 official and recently completed incident investigations from all six regionalsupervisory authority offices in Sweden was performed. Data was examined per nature of the investigation, numberof 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.<br/><br/>Results:<br/>With different investigation methods in use, this incident reporting system still seems to contribute to are production of an organisational micro-level understanding of how risks emerge with a focus that operates inthe 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 endof the healthcare system adapt to new legislation and organisational change by balancing rhetoric and practiceduring fulfilment of stated obligations.<br/><br/>Conclusions:<br/>Our findings support that traditional linear causality construction and traditional norms remain intactdespite new legislation and recent organisational change. Through efficient and adapted working procedures bythe main actors, this model still brings societal closure of harm and thereby a way to focus on moving on forward},
  author       = {Wrigstad, Jonas and Bergström, Johan and Gustafson, Pelle},
  issn         = {2056-5917},
  keyword      = {Adverse event,Incident investigation,Healthcare,Legislation,Ontology},
  language     = {eng},
  month        = {10},
  number       = {13},
  publisher    = {BioMed Central},
  series       = {Safety in Health},
  title        = {On safety ontology : A cross-section analysis of incident investigations in a public healthcare system},
  url          = {http://dx.doi.org/10.1186/s40886-017-0064-7},
  volume       = {3},
  year         = {2017},
}