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THE WEAKEST LINK INTER-ORGANISATIONAL COMMUNICATION ABOUT (NEAR-) INCIDENTS IN THE HEALTH CARE CHAIN

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Where people work, things may go wrong, mistakes happen, and systems fail. The health care system is an example of a complex environment, where mistakes happen. Worst-case scenario, patients die because of things that go wrong, because of (near-) incidents. As many researchers have argued, learning from (near-) incidents depends mainly on insufficient intra-organisational communication. Professionals need to be informed of what had happened. Professionals need to communicate to each other about (near-) incidents to avoid at least the negative outcomes. Within the health care chain, professionals from different organisations and disciplines contribute within a linking system to the care of patients. Incidents in one link, e.g., the ambulance service, can have consequences for the delivery of care in another link, e.g., the hospital. Alternatively, incidents can be discovered later on in the chain. To learn from (near ) incidents that happen in other links, professionals need to share information between organisations. Professionals need to communicate between organisations to create inter-organisational learning.
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... To improve transitional patient safety, it is vital that healthcare professionals in primary and secondary care understand each other's working methods, and practice good communication and openness [10]. Many emphasize the need for a system-based approach in healthcare in which the patient has a central role [11,12]. ...
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