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    Make healthcare safer with transmural incident reporting

    Last modified: July 11 2017

    Transmural incident reporting

    If the improvement of patient safety is at issue, healthcare providers tend to look only within their own department or institution. Attention is paid to safety along the integrated care chain, but this does not (yet) reach outside the perimeter of their own institution. It is predominantly older patients who are subject to multi-disciplinary integrated care involving more than one organisation. This is known as transmural integrated care.

    This blog describes how transmural incident reporting works and how it contributes to patient safety.

    Status of transmural incident reporting in healthcare

    "Patient safety in the transmural integrated care chain is still in its infancy".

    Research within the acute integrated care chain (general practitioners, ambulance care, first aid, mobile medical teams and the mental healthcare crisis team) indicates that the responsibility for patient safety in transmural integrated care is insufficiently embedded (Hesselink et al, 2016). Managers and care professionals have their own legitimate reasons for this undesirable situation, but they are not happy with it. The causes of this situation include:

    • The autonomous positions of the healthcare providers.
    • Internal organisational interests.
    • The patient safety policies of the parties within the integrated care chain.

    "Risk analysis and subsequent improvements are often ad-hoc".

    In the acute integrated care chain, partners work in their own organisations on the preconditions for patient safety. Each integrated care provider reports incidents and conducts prospective risk inventories. However, this does not hold true for the transmural integrated care chain; risks are not researched or examined in a systematic manner.

    It is therefore important to gain insight into the risks within the transmural integrated care chain in order to take patient safety to the next level.

    Improve patient safety

    Causes of incidents
    1.  Administration & planning 
    Incidents related to administrative issues or planning include: 
    • Incorrect agreements and/or conventions 
    • Mix-up of patient data in medical records 
    • No resuscitation statement or referral in place 
    2. Medication 
    Incidents related to the dispense of medication include: 
    • Wrong dose of prescription indicated  
    • Wrong medication supplied 
    • Incomplete or incorrect medication hand-over conducted.
    3. Medical content-wise 
    Incidents related to patient examination include: 
    • Delayed/incorrect examination results
    • Incorrect examination application 
    • Digression from protocols and working agreements 
    4. Communication 
    Incidents related to internal communication include: 
    • Admission and discharge communication issues 
    • Miscommunication 
    • Improper treatment


    "Transmural reporting makes healthcare safer".

    Transmural incident reporting visualises the risks in the transmural integrated care chain and supplies important operational control information. Reported incidents can vary in terms of content but they do provide insight into the weaker links within the integrated care chain (see text box). Targeted improvements can be made by anticipating and interpreting the value of this information.

    "A general practitioner receives a discharge notification about a patient. During the home visit it becomes clear that the patient was not discharged, but died".

    During a four-month trial within a transmural integrated care chain, no fewer than 33 adverse events and near misses were reported. The conclusion drawn was that care professionals are prepared to report incidents in the assumption that the reported incidents are but the tip of the iceberg. The trial was therefore expanded into a transmural incident reporting project with the objective of:

    • Reporting and registering undesirable events in the transmural integrated care process;
    • Analysing incidents, whereby the root causes of the incidents are determined;
    • Formulating improvement measures as required and if possible – to prevent similar incidents occurring in the future and to improve the quality of patient care;
    • Providing feedback related to the analyses and improvement measures to the reporting party.

    The trial indicated that most incidents result from miscommunication in the hand-over between the care provider partners. For example, a general practitioner who receives the discharge notification about a patient, but only during the home visit does it become apparent that the patient has not been discharged, but passed away.

    "Transmural incident reporting leads to greater understanding of each other's work and healthcare improvements".

    The network appointed a Transmural Committee for Incident Reporting, comprising general practitioners, pharmacists, hospital medical staff and a hospital safety consultant. All incoming incidents reported were analysed by the committee. An assessment was then made as to whether improvement measures should be implemented. The network came to the conclusion that transmural incident reporting did indeed lead to healthcare improvements. In addition, care professionals developed greater understanding of each other’s work: an important precondition for safety enhancements. These promising experiences encouraged other institutions to reach out to and team up with the network.

    Transmural incident reporting with TPSC Cloud™

    TPSC Cloud™ is a Quality & Risk Management System that facilitates transmural incident reporting. Incoming notifications are easily shared with committee members with the help of integrated e-mail functionality. The effectiveness of subsequent improvement measures is communicated in exactly the same way to not only committee members, but also to the incident reporter.

    Moreover, with the help of various analysis methodologies such as the Fishbone Diagram, PRISMA or the HFMEA, the root causes of incident origin can be put on the radar screen. Weaknesses in existing processes are revealed, whereby risks for both patients and professionals in the transmural integrated care chain are reduced while, at the same time, quality is boosted.

    Like to learn more bout incident reporting and analysis and how this improves patient safety? Download the Incident Management e-book: 

    e-book Incident Management

    Wendy Rientjes, 2 February 2017


    Eliel, M., Bilijam, C., & Miedema, C. (2013, March). Transmuraal melden maakt zorg veiliger. Retrieved from https://www.medischcontact.nl/nieuws/laatste-nieuws/artikel/transmuraal-melden-maakt-zorg-veiliger.htm 

    Ridder, den, K. (2011, October). Geef ze een veiligheidsbril! Vakblad voor opleiders in de gezondheidszorg, pp. 9-12. Retrieved from http://www.vmszorg.nl/_library/9419/Geef%20ze%20een%20veiligheidsbril!pdf 

    Slootweg, I., Busch, O., & Lombarts, K. (2016, June). Opleiden voor een veilige bespreekcultuur. KIZ, pp. 11-13

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