Where people work, things go wrong, mistakes happen, and systems fail. The health care system is an example of a complex environment in which mistakes happen. Worst-case scenario, patients die because of things that go wrong, because of (near-) incidents. Central to this study, is the 'exchange of information about (near-) incidents'. It is explored with whom professionals communicate about (near-) incidents within the chain, with what goal this communication takes place and the assumptions professionals have about (near-) incidents. Explored is if tolerance and decisiveness stimulate inter-organisational learning, if incident characteristics (severity and likelihood of occurrence) play a role in communication between different professionals in the health care chain, and how attribution processes are linked to communication about (near-) incidents. Although tolerance and decisiveness within an organisation stimulate learning, intolerance and indecisiveness between organisations do not necessarily hinder inter-organisational communication. Even if professionals did experience negative reactions when transferring information, this did not stop them communicating about (near-) incidents, it sometimes changed the way they communicated. There was no overall agreement among professionals about the definition of an incident. In the process of learning from (near) incidents between different links in the chain, the content of the message differs and hinders inter-organisational knowledge sharing. Attribution processes affect communication about (near-) incidents. (Near-) incidents that are attributed to internal, unstable, controllable causes are not communicated with other parties involved and therefore hinder double loop learning. Especially the combination of a high level of autonomy combined with first order problem solving seems to hinder communication and therefore learning from (near-) incidents. A chain-wide incident-reporting system can create double loop learning; can create a 'health care chain memory'. The downside of such an overall, chain-wide incident-reporting system is that it can turn into a bureaucratic, time-consuming ‘Juggernaut’ that professionals are obliged to use. A strong chain balances differentiation and integration. Links in that chain acknowledge that inter-organisational knowledge sharing between different links is inevitable for second order learning. In order to create a shared 'health care chain culture', to create a chain that learns from (near-) incidents, professionals have to communicate beyond the walls of their own organisation, as the chain is as strong as its weakest link.
|Qualification||Doctor of Philosophy|
|Award date||9 Nov 2012|
|Place of Publication||Enschede|
|Publication status||Published - 9 Nov 2012|