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Objectives: The goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports., Methods: Based on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied., Results: In the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement., Conclusion: The RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Incident reporting systems (IRSs) have been widely adopted in healthcare, calling for the investigation of serious incidents to understand what causes patient harm. In this article, we study how the Dutch IRS contributed to social and participative learning from incidents. We integrate quantitative and qualitative data in a mixed-methods design. Between 1 July 2013 and 31 March 2019, Dutch hospitals reported and investigated 4667 incidents. Healthcare inspectors scored all investigations to assess hospitals' learning process following incidents. We analysed if and on what aspects hospitals improved over time. Additionally, we draw from semi-structured interviews with incident investigators, quality managers, healthcare inspectors and healthcare professionals. Healthcare inspectors score incident investigation reports better over time, suggesting that hospitals conduct better investigations or have become adept at writing reports in line with inspectors' expectations. Our qualitative data suggests the IRS contributed to practices that support social and participative learning-the professionalisation of incident investigation teams, the increased involvement of patients and families in investigations-and practices that do not-not linking learning from the investigation teams to that of professionals, not consistently monitoring the recommendations that investigations identify. The IRS both hits and misses the mark. We learned that IRSs need to be responsive to the (developing) capabilities of healthcare providers to investigate and learn from incidents, if the IRS is to stimulate social and participative learning from incidents., Competing Interests: Declaration of competing interest IL and MV work as inspectors for the Dutch Health and Youth Care Inspectorate. Both IL and MV have been and are involved in the process of designing the IRS and MV is part of a team of inspectors scoring hospital SE reports. IL and MV did not participate in qualitative data collection., (Copyright © 2020 The Author(s). Published by Elsevier B.V. All rights reserved.)

The prevention of safety incidents (SI) in health and social care settings is an ongoing undertaking. Limited research has been conducted on SIs outside of acute care. Internationally residential care facilities (RCFs) are typically regulated to promote quality and safeguarding. A part of this regulation is the statutory responsibility of RCFs to notify the regulator about SIs. Notifications include details surrounding SIs and are used to inform the regulatory monitoring approach. The recent development of the Database of Statutory Notifications from Social Care in Ireland facilitates in‐depth analysis of notifications which can be used to inform the management of SIs and thus, improve quality and safety. The aim of this study was to analyse narratives provided in statutory notifications for older persons and people with disability, in order to identify current management of SIs, system vulnerabilities and reporting practices. A Qualitative Descriptive approach was taken. A random sample of notifications received in 2018 was drawn and stratified by service‐type and notification‐type. Data extraction was conducted against priori agreed target areas of management, system vulnerabilities and reporting practices. Inductive thematic analysis was used identifying two parent themes: 'chronology' and 'regulatory input'. 'Chronology' subthemes included 'pre‐event', 'immediate response' and 'continued response'. Measures that are resident focused and follow policies and protocols in RCFs to prevent or mitigate the seriousness of SIs were evident in the immediate response and continued response. The actions taken in the immediate and continued response in turn became part of the pre‐event of future SIs. Under 'regulatory input' subthemes included 'inaccurate reporting', 'lines of inquiry', 'requests for further information', 'identification of repetitive patterns' and 'satisfactory conclusion'. In conclusion, RCFs manage SIs with short and longer term actions focused on resident wellbeing. These actions in turn become part of the pre‐event of future SIs. Regulatory input highlighted regulatory burden. [ABSTRACT FROM AUTHOR]

Background The Dutch healthcare inspectorate publishes its inspection frameworks to inform both the public and healthcare providers about regulatory procedures and in the hope that publication will motivate healthcare providers to improve quality and comply with standards. This study explores the consequences of publishing these frameworks for the regulation of quality and safety in healthcare. Methods We selected recently published inspection frameworks used in three healthcare settings: nursing home care, dental care and hospital care. We conducted 37 interviews with 39 respondents (healthcare professionals, managers, quality offcers, policy advisers and inspectors) and explored their awareness of and experiences with these frameworks. We held a group interview with three inspectors to refect on our fndings. All data underwent thematic content analysis. Results We found that the institutional infrastructure of a sector plays an important role in how an inspection framework is used after publication; particularly the presence and maturity of quality improvement work in the sector and the inspectorate's grip on a sector matter. Respondents mentioned differences in framework use in organisational contexts, particularly relating to scale. In some organisations, the framework served as an accountability mechanism to check if quality meets basic standards, while in other organisations professionals adopted it to stimulate discussion and learning across teams. Conclusion Publication of inspection frameworks might result in quality improvement work, and in particular contexts could be used as a regulatory strategy to target quality improvement in a healthcare sector. For this, it is important that regulators consider the capabilities and possibilities for learning and improving within a sector. [ABSTRACT FROM AUTHOR]

Many nations, healthcare organizations and interest groups are addressing the question of how patients can best be involved in designing and executing patient safety policy. Looking back at how patient engagement has developed in healthcare, we can draw lessons on how to engage patients in patient safety. [ABSTRACT FROM AUTHOR]

To describe the development of an analyzable database of statutory notifications received from long-term care facilities (LTCFs) and to describe trends in receipt of notifications from 2013 to 2019. Description of database development with descriptive and trend analyses. LTCFs for older persons and for people with disability in Ireland. Data on notifications received and on centers were extracted from a system internal to the health and social services regulator and combined into an analyzable database. Variables were screened for personal information, cleaned, transformed, or redacted and combined into a database suitable for open access publication. Descriptive analyses of the volume of notifications, trends over time and breakdown by service type, notification type, and risk-rating were conducted. The Database of Statutory Notifications from Social Care in Ireland was developed and an open access version published in February 2021. Protection of personal data was an important consideration in publishing the data publicly. Uses of the database include examination of national trends and identification of determinants of adverse events and areas for quality improvement. The number of notifications received increased over time. Quarterly notifications contributed to the largest proportion of notifications (older persons, 36.7%; disability, 39.1%). This was followed by serious injury notifications in LTCFs for older persons (33.3%) and abuse allegation notifications in LTCFs for people with disability (36.0%). Less than 1% of individual notifications were risk-rated red (highest severity level of impact on resident welfare). The types of notifications that were collectively risk-rated highest were staff misconduct, abuse allegations, and outbreaks of infectious disease. The methodology and findings can inform publications of notifications, planning and resourcing for receipt and submission of notifications, target areas for quality improvement initiatives, mandating of timelines for receipt of notifications, and the mandating of notifications in legislation. [ABSTRACT FROM AUTHOR]