Need to learn from incidents and near misses in the health care chain

November 12, 2012

Approximately 1,735 patients a year on average die in the Netherlands as a result of mistakes. Health care professionals try to learn from these incidents and near misses, but the learning process is often confined within the individual organizations and the individual links in the health care chain. But incidents and near misses occur just as much when patients are referred from one link to another. Research into communication between the various links on incidents and near misses shows up the weak spots in the learning process within the chain. On 9 November 2012 Greet van der Kaap, research lecturer at Windesheim University of Applied Sciences in Zwolle, is to receive her PhD from the University of Twente on 'The Weakest Link, inter-organisational communication about (near) incidents in the health care chain'.

Patients and professionals in the health service depend on the correct transfer of from one link to another. If the information on a patient's is incorrect, an ambulance paramedic cannot provide the right care on the way to hospital. Or if a patient is allergic, everyone in the chain needs to know this. Something can go wrong in a link and only be discovered later on. can learn from these incidents and near misses by communicating about them.

Apples and oranges

But does every part of the chain speak the same language? Greet van der Kaap's study shows that different professions define incidents and near misses differently. Pharmacists and nurses often give specific examples, such as the wrong medication or mix-ups with names. For physicians and specialists this is much more of a grey area, concerning whether diagnoses are missed. In effect this is like comparing apples and oranges, and it hampers the between the various links.

Problem-solving ability

According to Van der Kaap, the combination of a high degree of problem-solving ability and a high degree of autonomy hampers communication on incidents and near misses, as can be seen for example in the case of GPs, specialists and nursing home doctors. The problem is solved: it's gone, so why talk about it? Professionals with a lower degree of autonomy, such as pharmacists and , are more likely to communicate with other professions, as they are not allowed to take decisions on medicines themselves, they cannot prescribe a solution if something goes wrong. For the sake of inter-organizational learning, however, it is important for all professionals to communicate about incidents and near misses.


Van der Kaap puts forward some solutions to improve learning within the health care chain. This will require a good balance between differentiation and integration. Professionals need to realize that they form part of a chain, and communication with one another on incidents and near misses is vital. Providing feedback to professionals in other links is inextricably linked with inter-organizational learning. A reporting system covering the entire chain, for example with certain weeks scheduled for reporting (putting everyone on alert every so often) could also help – provided it is organized in such a way that it does not involve a lot of red tape or place excessive demands on scarce resources such as time and money.

Explore further: Increased collaboration between nursing home RNs and LPNs could improve patient care

Related Stories

Increased collaboration between nursing home RNs and LPNs could improve patient care

March 14, 2012
Researchers estimate nearly 800,000 preventable adverse drug events may occur in nursing homes each year. Many of these incidents could be prevented with safety practices such as medication reconciliation, a process in which ...

Survey reveals reasons doctors avoid online error-reporting tools

October 5, 2011
"Too busy," and "too complicated." These are the typical excuses one might expect when medical professionals are asked why they fail to use online error-reporting systems designed to improve patient safety and the quality ...

NHS ill prepared to care for obese patients

July 26, 2011
The NHS is poorly prepared to care for obese patients, lacking dedicated equipment and adequately trained staff, among other things, reveals an analysis of patient safety incidents, published online in Postgraduate Medical ...

Circulating nurses recover errors in cardiovascular operating room

June 5, 2012
(HealthDay) -- Circulating perioperative nurses can help reduce surgical errors and incidents in the cardiovascular operating room (OR) and improve patient safety, especially with regard to surgical prepping and aseptic technique, ...

Recommended for you

In a nutshell: Walnuts activate brain region involved in appetite control

August 17, 2017
Packed with nutrients linked to better health, walnuts are also thought to discourage overeating by promoting feelings of fullness. Now, in a new brain imaging study, researchers at Beth Israel Deaconess Medical Center (BIDMC) ...

Energy dense foods may increase cancer risk regardless of obesity status

August 17, 2017
Diet is believed to play a role in cancer risk. Current research shows that an estimated 30% of cancers could be prevented through nutritional modifications. While there is a proven link between obesity and certain types ...

Technology is changing Generation smartphone, and not always for the better

August 16, 2017
It's easy to imagine some graybeard long ago weighing in on how this new generation, with all its fancy wheels, missed out on the benefits of dragging stuff from place to place.

The environmental injustice of beauty

August 16, 2017
Women of color have higher levels of beauty-product-related chemicals in their bodies compared to white women, according to a commentary published today in the American Journal of Obstetrics and Gynecology. The authors say ...

Heavily used pesticide linked to breathing problems in farmworkers' children

August 15, 2017
Elemental sulfur, the most heavily used pesticide in California, may harm the respiratory health of children living near farms that use the pesticide, according to new research led by UC Berkeley.

Taking a stand on staying mobile after 80

August 14, 2017
(HealthDay)—If you want to stay as fit as possible well into your 80s, the answer may be as simple as standing on your own two feet.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.