Despite continued calls to learn from patient safety incidents and a tradition of incident investigations in healthcare, there is discussion about if and how learning from incidents occurs. In this article, we study a policy change in the Netherlands that aims to encourage organisations to learn more from incidents. Dutch healthcare organisations investigate their own incidents. Recently, the Dutch government decided that when an incident leads to the death of a client in elderly or disabled care, an external chair should head the investigation committee. Thinking of learning as social, participative practice, we asked how and under what conditions an external chair might help organisations learn from incidents. We adopted a qualitative research design. We asked healthcare inspectors to assess 20 incident investigation reports by committees with (10) and without an external chair (10), using what we learned in follow-up interviews and a focus group. We interviewed investigation committee chairs, professionals involved in incidents, quality advisers and directors of four healthcare organisations (n = 15) to study how they investigated incidents with external chairs. We also interviewed external chairs, healthcare inspectors and other stakeholders (n = 15). Our respondents valued external chairs’ methodological expertise and experience in investigating incidents. The external chair's outsider's position enables critical, impartial inquiry. Besides helping organisations identify root causes of an incident, both external chairs and organisations learn from investigating an incident. Our article contributes to literature on (shared) learning from incidents by envisioning of the external chair as fostering a social and participative form of shared learning.

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Keywords Incident investigation, Organisational learning, Patient safety, Shared learning
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Journal Safety Science
de Kam, D. (David), Grit, K.J, & Bal, R. (Roland). (2019). Shared learning from incidents: A qualitative study into the perceived value of an external chair on incident investigation committees. Safety Science, 120, 57–66. doi:10.1016/j.ssci.2019.06.031