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Introduction
Incident reporting is widely recognised as an important method for improving safety in healthcare, and many countries have established their own incident reporting systems. 1 However, the actual value of these systems is increasingly subject to debate. 2 Reporting systems, both local and national, are overwhelmed by the volume of reports and fall short in defining recommendations for improving healthcare safety: 'We collect too much and do too little'. 3
The purpose of these systems is also under debate. The UK, for example, struggles to clarify whether incident reports should be used to help healthcare organisations learn, or whether they should help regulators and funders to make judgements. 4 As healthcare inspectors tasked with running a national hospital incident reporting system (IL, SM and JV), we recognise the issues described above. In this article, we show how the theories in the evolving scientific literature on incident reporting apply to our situation. Our work since 2012 acts as an empirical example of how reporting systems could have an effect if they focus on the learning process within hospitals instead of on solutions for reported safety issues. As TS Eliot is quoted as saying: "The journey, not the arrival, matters."
Learning how to hit a moving target
The conception of 'incident' changes over time
Box 1 Sentinel event A sentinel event (Dutch: calamiteit) is defined in the 1996 Healthcare Organisations Quality Act as an unintended and unexpected event, related to the quality of care and having caused death or serious harm to the patient. All healthcare organisations are mandated to report sentinel events to the Healthcare Inspectorate within 3 days after discovery.
Standards for corrective actions change over time
Just as the standards for what is defined as incident shift, so do the standards for corrective actions. For example, Behr et al 7 conducted research into three healthcare incidents that attracted significant public attention. These were a paediatric cardiology case in 2001, a cardiothoracic case in 2005 and a neurology case in 2009. Although the cases were similar in many respects, the authors found a shift in the way the cases were perceived. The 2001 case was seen as a professional problem, the 2005 case a managerial problem and the 2009 case a governance problem....