Background Despite two decades of promoting systems-based approaches, healthcare safety investigations often fail to produce system-level changes. This study analyzed the quality of recommendations from serious incident investigations conducted by multidisciplinary teams in Finland. Methods Serious incident investigation reports (n = 169) from 2018 to 2023 were collected from 11 well-being services counties, with a total of 525 recommendations being extracted and classified as weak, intermediate, or strong according to the US Department of Veterans Affairs’ National Center for Patient Safety criteria. Each recommendation was assigned only to one strength category. Results More than half of all recommendations were weak (56%) and focused mainly on staff training (43%) and new procedures or policies (39%). Intermediate recommendations comprised 37%, primarily targeting documentation and communication (63%), while only 7% were strong. Approximately one in four investigations (24%) included at least one strong recommendation. Mentions of recommendations being implemented were rare (20%), and only 7% included follow-up notes. None of the reports specified the analytical method used. Conclusions Finnish healthcare's serious incident investigations produce predominantly weak, behavior-focused recommendations that are seldom followed-up or implemented. The absence of standardized reporting formats and limited documentation of follow-up hinder the evaluation of impact. To strengthen patient safety, investigations should yield fewer, but stronger, system-oriented recommendations developed using structured analytical methods and evaluated through consistent national guidance and monitoring mechanisms.
Liukka et al. (Wed,) studied this question.