Processing incident reports involving integrated care

The Health and Youth Care Inspectorate receives approximately 10,000 reports of incidents in healthcare each year. These reports come from citizens, care providers, manufacturers and other agencies.

Most reports concern incidents that happen when one single care provider is responsible. However, the report can also regard incidents during collaboration between several care providers involved in a client’s network. We call this ‘network incident reports’. The care providers involved are then jointly responsible for investigating the causes of these incidents. They are also jointly responsible for providing a research report to the Inspectorate.

Joint learning

  • If things go wrong, the Inspectorate expects the care providers involved to be willing to learn about the incident in a care network. We expect them to learn with each other, and from each other. The care providers can decide for themselves how they do this. In practice the Inspectorate sees that: Healthcare providers conduct joint research by commissioning an external researcher;
  • The care provider who is most experienced in investigation of adverse healthcare events conducts the investigation. The other parties then cooperate and participate in this investigation.
  • Each care provider conducts his/her own investigation. Afterwards, the different parties involved discuss the results and learn from it in a joint meeting.

The ultimate goal of joint learning is that collaboration in the care network improves. And thus improve healthcare in general.