scholarly journals An Organizational Learning Framework for Patient Safety

2016 ◽  
Vol 32 (2) ◽  
pp. 148-155 ◽  
Author(s):  
Marc T. Edwards
Keyword(s):  
Patient Safety ◽  
Organizational Learning ◽  
Human Error ◽  
High Reliability ◽  
Organizational Capabilities ◽  
Organizational Learning Theory ◽  
Culture Of Safety ◽  
Learning Framework ◽  
Operational Improvement ◽  
Learning Modes

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

Teaching the Culture of Safety

2011 ◽  
Vol 16 (3) ◽  
Author(s):  
Jane Barnsteiner
Keyword(s):  
Patient Safety ◽  
Nursing Education ◽  
Healthcare Professionals ◽  
High Reliability ◽  
Essential Elements ◽  
High Reliability Organizations ◽  
Culture Of Safety ◽  
Safety Science ◽  
Licensure Programs

Although a healthcare culture of safety has been a practice priority for many years, there has been less attention to incorporating culture of safety content into the education of healthcare professionals. Students need to become knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting utilization of safety science will lead to safer care for patients and families. Learning about both patient safety and system vulnerabilities needs to begin in pre-licensure programs and become an integral part of learning in all phases of nursing education and practice. In this article the author will begin by reviewing the essential elements of a culture of safety and considering what students need to know about a culture of safety. She will describe activities that promote safety, high reliability organizations, and external drivers of safety, and conclude by offering strategies for integrating a culture of safety into the curriculum.

Applying Organization Theory to Understanding the Adoption and Implementation of Accountable Care Organizations

2016 ◽  
Vol 73 (6) ◽  
pp. 694-702 ◽  
Author(s):  
Stephen M. Shortell
Keyword(s):  
Organizational Learning ◽  
Learning Theory ◽  
Organization Theory ◽  
High Reliability ◽  
Reliability Theory ◽  
Accountable Care Organizations ◽  
Accountable Care ◽  
Multiple Perspectives ◽  
Organizational Learning Theory ◽  
High Reliability Theory

This commentary highights the key arguments and contributions of institutional thoery, transaction cost economics (TCE) theory, high reliability theory, and organizational learning theory to understanding the development and evolution of Accountable Care Organizations (ACOs). Institutional theory and TCE theory primarily emphasize the external influences shaping ACOs while high reliability theory and organizational learning theory underscore the internal fctors influencing ACO perfromance. A framework based on Implementation Science is proposed to conside the multiple perspectives on ACOs and, in particular, their abiity to innovate to achieve desired cost, quality, and population health goals.

The Nature of Entrepreneurial Opportunities: Understanding the Process Using the 4I Organizational Learning Framework

2005 ◽  
Vol 29 (4) ◽  
pp. 425-449 ◽  
Author(s):  
Dev K. Dutta ◽  
Mary M. Crossan
Keyword(s):  
Organizational Learning ◽  
Learning Theory ◽  
Theory And Practice ◽  
Organizational Learning Theory ◽  
Learning Framework ◽  
Entrepreneurial Opportunities

In this article, we drew upon insights from two rather disparate streams of literature—entrepreneurship and organizational learning—to develop an informed understanding of the phenomenon of entrepreneurial opportunities. We examined the nature of entrepreneurial opportunities from two contrasting views—Schumpeterian and Kirznerian—and delved into their ontological roots. By applying the 4I organizational learning framework to entrepreneurial opportunities, we were able to not only resolve the apparently conflicting explanations of opportunities arising out of the contrasting ontological positions but also to achieve a level of pragmatic synthesis between them. In highlighting the article's contributions to theory and practice, we suggest that just as research on entrepreneurial opportunities benefits from applying organizational learning theory, so is organizational learning informed by research arising within the field of entrepreneurship studies.

Human Factors in the Wild Delivering Safety in the Pediatric World (Discussion Panel)

2017 ◽  
Vol 61 (1) ◽  
pp. 620-624 ◽  
Author(s):  
Adjhaporn (Nana) Khunlertkit ◽  
Shanqing Yin ◽  
A. Joy Rivera ◽  
Patrice Tremoulet ◽  
James Won ◽  
...  
Keyword(s):  
Patient Safety ◽  
Human Factors ◽  
Pediatric Patient ◽  
Human Error ◽  
High Reliability ◽  
Human Factors Engineering ◽  
Healthcare Settings ◽  
Increase Risk ◽  
In The Wild ◽  
Pediatric Healthcare

The pediatric healthcare environment is arguably more complex than the general, adult, healthcare settings (e.g., weight based dosing, caring for patients who cannot advocate for themselves, etc.). These complexities and the ever-changing dynamics of the pediatric patient population and their families increase risk of healthcare professionals committing errors that may result in patient harm. Moreover, due to their physiologic state, when pediatric patients incur such errors their impact is exacerbated due to the fact that children are often less capable of recovering from such events. Human Factors Engineering can help promote a culture of safety and high reliability by using proven techniques to understand human fallibility and help prevent or mitigate human error in healthcare. This panel invites six diverse healthcare HF practitioners from different organizations to share their experiences, contributions, and the impacts they have made to improve pediatric patient safety. Our panel will provide a unique lens on the application of HF approaches, and what sensitive factors toned to be considered to successfully enhance pediatric patient safety.

Human Factors to Minimize the Human Error and Improving Patient Safety

2011 ◽  
Vol 1 (11) ◽  
pp. 82-86
Author(s):  
Sanjay Saproo ◽  
◽  
Dr. Sanjeev Bansal ◽  
Dr. Amit Kumar Pandey
Keyword(s):  
Patient Safety ◽  
Human Factors ◽  
Human Error

scholarly journals Understanding safety in healthcare: the system evolution, erosion and enhancement model

2013 ◽  
Vol 2 (3) ◽  
pp. 25 ◽  
Author(s):  
Jane Carthey
Keyword(s):  
Patient Safety ◽  
Complex Systems ◽  
Human Error ◽  
Improve Patient Safety ◽  
New Model ◽  
System Evolution ◽  
Accident Causation ◽  
System Migration ◽  
Improve Patient

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety.

scholarly journals Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

2020 ◽  
Author(s):  
J Wailling ◽  
Brian Robinson ◽  
M Coombs
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
New Zealand ◽  
Health Care Professionals ◽  
Nuclear Power ◽  
High Reliability ◽  
Health Care Systems ◽  
Tertiary Hospital ◽  
Structured Interviews

© 2018 John Wiley & Sons Ltd Aim: This study explored how doctors, nurses and managers working in a New Zealand tertiary hospital understand patient safety. Background: Despite health care systems implementing proven safety strategies from high reliability organisations, such as aviation and nuclear power, these have not been uniformly adopted by health care professionals with concerns raised about clinician engagement. Design: Instrumental, embedded case study design using qualitative methods. Methods: The study used purposeful sampling, and data was collected using focus groups and semi-structured interviews with doctors (n = 31); registered nurses (n = 19); and senior organisational managers (n = 3) in a New Zealand tertiary hospital. Results: Safety was described as a core organisational value. Clinicians appreciated proactive safety approaches characterized by anticipation and vigilance, where they expertly recognized and adapted to safety risks. Managers trusted evidence-based safety rules and approaches that recorded, categorized and measured safety. Conclusion and Implications for Nursing Management: It is important that nurse managers hold a more refined understanding about safety. Organisations are more likely to support safe patient care if cultural complexity is accounted for. Recognizing how different occupational groups perceive and respond to safety, rather than attempting to reinforce a uniform set of safety actions and responsibilities, is likely to bring together a shared understanding of safety, build trust and nurture safety culture.

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