Interorganisational Patient Safety Incident Reports: An Analytical Perspective

AIM: To obtain information on what kinds of patient safety incidents were reported between different healthcare organisations, which professional groups reported them, and what kind of development measures were planned to prevent recurrence of the patient safety incidents. DESIGN: The data of this retrospective register study consisted of interorganisational patient safety incident reports (n = 1225) entered in the electronic incident reporting system from 2015 to 2021. METHODS: The reports were sent to the university hospital from other healthcare organisations belonging to the university hospital's specific catchment area in Finland. Numeric data were analysed using descriptive statistical methods and open-ended answers reporting development measures (n = 139) with inductive content analyses. RESULTS: The majority of reported incidents between organisations were related to information flow and management (57%). The second most reported concerned medication, fluid therapies, blood transfusions, contrast, and marker patient safety incidents. Most of the reports were prepared by nurses, followed by physicians and other stakeholders. Many of the patient safety incidents reported were categorised as insignificant or low risk (67%). The type of incidents was usually 'incidents occurring to the patients', causing minor risk to the patient. Only a few interorganisational development measures were suggested. CONCLUSIONS: Collaboration between healthcare organisations should be improved to ensure timely and high-quality information transfer regarding the safe continuity of patient care. Incidents should be regularly reviewed and the planning of preventive measures for recurrent incidents should be conducted by interorganisational multi-professional teams, with the information in each organisation being disseminated at the unit level to improve safe care pathways. IMPLICATIONS FOR THE PROFESSION: To avoid variations in patient safety incident risk assessment and increase its reliability, the risk assessment should be performed by qualified assessors. IMPACT: This study showed that patient data transfer with adequate documentation and communication must be ensured for the continuity of care and patient safety. Development of interorganisational collaboration between professionals is needed to safeguard patient transfers from one healthcare organisation to another and ensure the patient's integrated care pathway. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.