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

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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References

Cooper

M. D.

(2000). Towards a model of safety culture. Safety Science, 36(2000), 111–136.

Ebright

P. R.

Patterson

E. S.

Render

MX.

(in press) The “New Look” approach to patient safety: A guide for clinical nurse specialist leadership. Clin Nurs Spec., 16(4).

Eisenlohr

Patterson

E. S.

Ebright

P. R.

Ford

D. K.

Render

MX.

(2001). Enhancing a Safety Culture: Assessment and Adult Learning Opportunities through Patient Safety Fairs. Proceedings of the 19th Annual Meeting VA Health Services Research: Improving Access and Outcomes. Washington D.C., February 14–16, p. 204.

Fischhoff

(1975). Hindsight does not equal foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1, 288–299.

Hutchins

(1995). Cognition in the Wild. Cambridge, MA: MIT Press.

DStSAG (1988). Basic Safety Principles for Nuclear Power Plants. (Safety Series Number 75-INSAG-3). International Nuclear Safety Advisory Group. International Atomic Energy Agency, Vienna.

Larson

C. E.

LaFasto

F. M. J.

(1989). Teamwork: What must go right/what can go wrong. Newbury Park: Sage publications.

Marsick

V. J.

(1988). Enhancing Staff Development in Diverse Settings. San Francisco: Jossey-Bass.

Patterson

E. S.

Cook

R. I.

Woods

D. D.

Render

MX.

(2001). New Arctic Air Crash Aftermath Role-Play Simulation: Orchestrating a Fundamental Surprise. Proceedings of the Human Factors and Ergonomics Society 45th annual meeting. 8–12 October, Minneapolis, MN, pp. 371–375.

10.

Reason

(1990). Human Error. Cambridge, MA: Cambridge University Press.

11.

Reason

(1997). Managing the Risks of Organizational Accidents. Ashgate Publishing Company.

12.

Render

M. L.

Patterson

E. S.

Ebright

P. R.

Lyons

Rice

Reed

Montague

Cook

R. I.

(2001). Qualitative analysis of adverse events with and without human performance expertise. National Quality and Safety Conference. 2–4 May, Las Vegas, NV.

13.

Ringstad

A.J.

Szameitat

S.A.

(2000). Comparative Study of Accident and Near Miss Reporting Systems in the German Nuclear Industry and the Norwegian Offshore Industry. Proceedings of the Human Factors and Ergonomics Society 44th annual meeting, 380–384.

14.

Rochlin

G. I.

Safe operation as a social construct. Ergonomics, 1999, Vol. 42, No. 11, 1549–1560.

15.

Terveen

L. G.

(1995). An overview of human-computer collaboration. Knowledge-Based Systems, 8, 67–81.

16.

Weick

K. E.

(1987). Organizational culture as a source of high reliability. California Management Review, Vol. XXIX, no. 2, 112–126.

17.

Woods

D. D.

Johannesen

L. J.

Cook

R. I.

Salter

N. B.

(1994). BehindHuman Error: Cognitive Systems, Computers, and Hindsight. Dayton, OH: CSERIAC.