Assessment and investigation
The Directorate of Health assesses reports of serious incidents in healthcare to determine whether and how to investigate them. An investigation aims to determine the cause of the incident and take steps to prevent it from happening again.
Serious incidents in healthcare can be varied and affect all aspects of patient care, including reception, information, examination, diagnosis, treatment, and follow-up. These incidents typically result from a combination of human and systemic factors. Therefore, the Directorate of Health must thoroughly investigate serious incidents from multiple angles, including gathering data and statements from those involved and conducting on-site visits. Investigations of serious incidents at the Directorate of Health can be quite extensive and time-consuming, depending on the nature of the incident. The investigation is conducted by specialists at the Directorate of Health, including physicians and nurses.
Serious incidents are commonly attributed to inadequate procedures and communication among health professionals or institutions, challenging working conditions (staffing, beds and housing), and insufficient electronic systems.
Recommendations for improvement
After investigating an unforeseen serious incident, the Directorate of Health provides recommendations for improvement. These recommendations are based on the incident findings and are typically directed to the reporting institution. Sometimes, incident conclusions may lead to recommendations for other health institutions or support services, such as electronic systems. The suggested improvements may include revising instructions and procedures, upgrading electronic systems, providing simulation training, and promoting a safety culture emphasising teamwork and communication. The Directorate of Health implements control measures when negligence is the primary cause of an incident.
