Reporting and investigating catastrophic incidents

Apart from being keen to learn from any undesirable incidents affecting our patient care services, it’s a fact that all hospitals in the Netherlands are required by law to comply with the Healthcare Quality, Complaints and Disputes Act. Under the terms of this Act, they are obliged to inform the Health and Youth Care Inspectorate about any matters related to the reporting and investigating of catastrophic incidents in relation to patient care.

How do we investigate catastrophic incidents?

We use the ‘Tripod Bèta method’ to investigate catastrophic incidents and potential catastrophes in relation to patient care. This method focuses on the underlying systemic causes of such incidents. In other words, it differs from a person-centred approach, which focuses on the actions taken by the healthcare-providers directly responsible for the care in question. We look at the context in which healthcare-providers make choices. We also identify the obstacles involved in managing the care process and in protecting patients.

Improving and monitoring the standard of care

Once the underlying causes have been identified, we draw up an action plan in conjunction with the department or departments concerned, with a view to improving the standard of care. All ensuing activities are recorded and monitored as part of our quality management system. Every four months, the Executive Board receives a report on the status of action based on the findings of investigations of catastrophic incidents. This enables the Board to monitor the implementation of the improvements.