Learning From Errors and Recoveries in Medical Chains


Tjerk W. van der Schaaf

Eindhoven University of Technology, Safety Management Group.




Most, if not practically all, systems for reporting and analysing medical incidents are based on and restricted to single, mono-disciplinary, hospital departments. Patients (or patient-related products such as blood or medicine) however usually "flow" through a series of (sub-) departments and healthcare-organisations outside of the hospital in the course their treatment, thus forming a "chain" . As shown in a dozen projects by our research group in a wide variety of medical domains during the last few years, some 15 -30 % of the causes of incidents in a single department may be "imported" from others, located earlier in the medical chain. This fact may then severely restrict a department's capability for learning lessons based on the analysis of incidents reported in that part of the chain only.

Examples are given of three recent or ongoing projects in the Netherlands, in transfusion medicine, care of asthmatic (COPD) patients, and medication errors. These projects were carried out explicitly to explore the benefits of "Chain-based" systems for reporting and analysing medical incidents, as opposed to the current Department-based ones. The prelimenary results show improved insight on the part of the medical staff ,as well as the necessity to consider new methods of analysis, fit to handle the sequential, time-related nature of these data.