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Abstract

A critical component of a high reliability organization (HRO) is believed to be a safety culture. Historically, healthcare placed the onus on individuals for perfection in performance of complex work. A six-month, case-based learning intervention at a public and private hospital, Safety Minutes™, attempted to shift the focus from the individual to systems. The intervention is organized in rotating modules of a medical and non-medical incident that exemplify a safety concept, displayed via posters in a staff meeting space, followed by a moderated discussion. Moderators asked how the stories resembled or differed from the nurses' experiences and guided participants away from ingrained “blame” responses in order to look more deeply at systemic and organizational factors. We assessed program effectiveness by ethnographic analysis of written transcripts of the moderated sessions and discuss lessons learned.

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Creating Patient Safety with Organizational Learning: A Case-Based Learning Intervention at a Public and Private Hospital

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