Incident investigations by the regulatory authority of Swedish healthcare – a 20-year perspective
Bibliographic record
Abstract
Objective: The purpose of this study was to describe procedural changes in hospital incident investigations and show the consequences of these changes over time.Methods: A two-stage method was used. First component of the study was a content analysis of 87 incident investigation sconducted 1995-2014 by the regulatory authority after adverse events in a Swedish university hospital. Second component was conducting semi-structured interviews with 11 investigators from all regulatory authority regional offices in Sweden.Results: In a minority of incident investigations, where further demands for action were required by the regulatory authority, a major portion of these were aimed at the micro-level. A plan for follow-up was expressed in only one tenth of the investigations. All investigators had a background from the healthcare system and saw this as advantageous. Their personal memory was claimed to be the only tool when referring to previous cases. Less fieldwork, more office work and more uniformity of language were recognised changes in comparison over time. The role of doing “auditing” was the most common description by the investigators themselves.Conclusions: The micro-level focus of the investigations reflected an organisational structure within the regulatory authority. We saw signs of parallel system weaknesses within the Swedish healthcare system with a clear absence of formalised organisational memory and a malfunctioning follow-up system of incident investigations. This can be seen both regarding the healthcare providers and the regulatory authority. The reports from the qualitative interviews data indicated that “auditing at the office” was considered the main occupation in incident investigations conducted by the regulatory authority.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.006 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".