596 / 879
▪
Event with total risk score of > 300
▪
Event frequency >50
▪
If Quality Committee decides so
(fe. score is below action level, but occurence is worrying)
Actions came top-down: Actions for improvement, escalated to manager
- often invented from behind desks
- who is going to do what?
- no multi-professional implementation
(although Quality Committee is multi-professional)
- yet well analysed (Prisma)
Continuous Improvement: Methods
Incident Registration
Discussion
Criteria for immediate action