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Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations
  1. Jonas Wrigstad1,2,
  2. Johan Bergström3,4,
  3. Pelle Gustafson2
  1. 1Department of Anesthesia and Intensive Care, Skåne University Hospital Lund, Lund, Sweden
  2. 2Department of Clinical Sciences, Lund University, Lund, Sweden
  3. 3Centre for Societal Resilience, Lund University, Lund, Sweden
  4. 4Centre for Risk Assessment and Management, Lund University, Lund, Sweden
  1. Correspondence to Dr Jonas Wrigstad; jonas.wrigstad{at}


Objectives Using the findings of incident investigations to improve patient safety management is well-established and mandatory under Swedish law. This study seeks to identify the mechanisms behind successful implementation of the recommendations of incident investigations.

Setting This study was based in a university hospital in southern Sweden.

Participants A sample of 55 incident investigations from 2008 to 2010 were selected from the hospital's incident reporting system by staff in the office of the chief medical officer. These investigations were initiated by 23 different commissioning bodies and contained 289 separate recommendations. We used a three-stage method: content analysis to code the recommendations, semi-structured interviews with the commissioning bodies focusing on which recommendations had been implemented and why, and data analysis of the coded recommendations together with data from the interviews.

Results We found that a clear majority (70%) of the recommendations presented to the commissioning bodies were targeted at the micro-level of the organisation. In nearly half (45%) of all recommendations, actions had been taken and a clear majority (73%) of these were at the micro-level. Changes in the management positions of the commissioning bodies meant that very little further action was taken. Other actions, independent of incident investigations, were often taken within the organisation.

Conclusions We conclude that two principles (‘close in space’ and ‘close in time’) seem to be important for bridging the gap between recommendation and implementation. The micro-level focus was expected because of the method of investigation used. Adverse events trigger organisational action independently of incident investigations.

  • Management
  • Patient safety
  • Adverse events
  • Investigation

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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