Exploring the “black box” of recommendation generation in local health care incident investigations: A scoping review (15 September 2023)

Summary

Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.

Content

This scoping review from Lea et al. looks at what approaches to incident investigation are used before the generation of recommendations, what are the processes for generating recommendations after a patient safety incident investigation, what are the number and types of recommendations proposed and what criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made.

The authors concluded that despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. They suggest that although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care.