Leren van incidenten in de zorg

Incidents in healthcare are often followed by an investigation to find out what happened and how it was possible for them to happen. It is often difficult to find good answers to these questions, partly because it is usually not possible for complex reality to be described in simple cause-and-effect reconstructions. Another objective of incident investigations is the prevention of incident reoccurrence. In this respect, answers are not simple either, as it is difficult to think of improvement measures that are both effective and easy to implement. As a result, incident reporting and investigation do not automatically lead to prevention of incident reoccurrence. It is, however, possible to recommend some measures that lead to better investigations and effective improvement measures after incidents.

Conflict of interest and financial support: potential conflicts of interest have been reported for this article. ICMJE forms provided by the authors are available online along with the full text of this article.