Erasmus School of Health Policy and Management, Erasmus University, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
Antoni van Leeuwenhoek / The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
Health Care Anal. 2022 Dec;30(3-4):254-274. doi: 10.1007/s10728-022-00447-3. Epub 2022 May 31.
Serious incident investigations-often conducted by means of Root Cause Analysis methodologies-are increasingly seen as platforms to learn from multiple perspectives and experiences: professionals, patients and their families alike. Underlying this principle of inclusiveness is the idea that healthcare staff and service users hold unique and valuable knowledge that can inform learning, as well as the notion that learning is a social process that involves people actively reflecting on shared knowledge. Despite initiatives to facilitate inclusiveness, research shows that embracing and learning from diverse perspectives is difficult. Using the concept of 'epistemic injustice', pointing at practices of someone's knowledge being unjustly disqualified or devalued, we analyze the way incident investigations are organized and executed with the aim to understand why it is difficult to embrace and learn from the multiple perspectives voiced in incident investigations. We draw from 73 semi-structured interviews with healthcare leaders, managers, healthcare professionals, incident investigators and inspectors, document analyses and ethnographic observations. Our analysis identified several structures in the incident investigation process, that can promote or hinder an actor's epistemic contribution in the process of incident investigations. Rather than repeat calls to 'involve more' and 'listen better', we encourage policy makers to be mindful of and address the structures that can cause epistemic injustice. This can improve the outcome of incident investigations and can help to do justice to the lived experiences of the involved actors in the aftermath of a serious incident.
严重事件调查——通常通过根本原因分析方法进行——越来越被视为从多个角度和经验中学习的平台：专业人员、患者及其家属。包容性原则的基础是，医护人员和服务使用者拥有独特而有价值的知识，可以为学习提供信息，以及学习是一个涉及人们积极反思共同知识的社会过程的观念。尽管有促进包容性的举措，但研究表明，接受和从不同角度学习是困难的。我们使用“知识不公正”的概念，指出某人的知识被不公正地取消资格或贬值的做法，分析了以了解为什么难以接受和从事件调查中提出的多种观点中学习。我们借鉴了对医疗保健领导者、管理人员、医疗保健专业人员、事件调查员和检查员的 73 次半结构化访谈、文档分析和民族志观察。我们的分析确定了事件调查过程中的几个结构，这些结构可以促进或阻碍参与者在事件调查过程中的知识贡献。我们不鼓励决策者重复“更多地参与”和“更好地倾听”的呼吁，而是鼓励决策者注意并解决可能导致知识不公正的结构。这可以提高事件调查的结果，并有助于在严重事件发生后为相关参与者的生活经历伸张正义。
