What Factors Influence Learning from PSEs?
Research Team:Liane Ginsburg, You-Ta ChuangPeter Norton, Whitney Berta, Deborah Tregunno, Peggy Ng and Julia Richardson
Learning in Context of Patient Safety
Learning from Patient Safety Events: Identification & reporting of patient
safety events Analysis of the causes of these events,
and Taking appropriate corrective action to
reduce reoccurrence of these events in the future
What we have known from our study
Five factors influenced sampled 49 hospitals engaging in learning activities following PSEs
1. Types of PSEs 2. Patient safety culture
Organizational leadership for patient safety Fear of repercussion
3. Patient safety training 4. Inter-organizational linkages 5. Ease of reporting
1. Types of Patient Safety Events
Major events Event analysis Dissemination of analysis and knowledge
Moderate events Minor events Major near misses
Differential learning responses among PSEs Saliency, limited resource capacity
2. Effects of Patient Safety Culture
Organizational leadership for patient safety The degree of shared beliefs about senior
management’s commitment to improve patient safety and quality of care
Example of 7 items: Senior management has a clear picture of the risk associated
with patient care
Fear of repercussion A collective perception of potential negative
reactions by others to patient safety failure events Example of 4 items:
I will suffer negative consequences if I report a patient safety problem
Organizational leadership for patient safety
2
2.5
3
3.5
4
2.43 4.93Organizational leadership for patient safety
Learning scores
Major eventanalysis (no effect)
Major eventdissemination
Moderate events
Minor events
Major near misses
Fear of repercussion
2
2.5
3
3.5
4
High LowFear of repercussion
Learning scores
Major event analysis(no effect)
Major eventdissemination
Moderate events
Minor events
Major near misses
3. Effects of Patient Safety Training
Learning from experience depends upon learning capacity
Training is an avenue to improve learning capacity Training has been found to be positively associated
with organizational performance
Manager’s patient safety training Promote “right” attitude toward patient safety failure Help subordinates deal with patient safety failure Items in the PCM survey
Receiving a formal quality/process improvement training program
Receiving a formal patient safety training program Attending patient safety conferences
Effects of patient safety training
1.5
2
2.5
3
3.5
4
0 3PCM training
Learning scores
Major eventanalysis (noeffect)
Major eventdissemination
Moderateevents
Minor events
Major nearmisses
4. Effects of Inter-organizational Linkages
Inter-organizational linkages facilitate information and experience transfer; as such they help organizations learn from others’ experiences.
Item in the PSO survey: Please list the hospitals/organizations you frequently
engage in discussion or information sharing regarding patient safety
The linkages tend to be: Nearby hospitals/Teaching hospitals Professional associations: Ontario Healthcare Risk
Management Network, Safer Healthcare Now!, Quality Healthcare Network, Canadian Patient Safety Institute
Mean: 3 hospitals/organizations, min=0, max=10
Effects of interorganizational linkages
2
2.5
3
3.5
4
4.5
0 10
Inter-organizational linkages
Learning scores
Major eventanalysis
Major eventdissemination
Moderate events
Minor events (noeffect)
Major near misses(no effect)
5. Ease of reporting
Theoretically, ease of reporting systems should have positive effects on learning responses to PSEs
However, the effects are complicated – the effects are influenced by fear of repercussion
Moderate events
2
2.5
3
3.5
4
Difficulty of reporting Ease of reportingReporting
Learning scores
Great fear ofrepercussion
Little fear ofrepercussion
Minor events
2
2.25
2.5
2.75
3
Difficulty of reporting Ease of reportingReporting
Learning scores
Great fear ofrepercussion
Little fear ofrepercussion
Summary/Implications Factors at organizational level influence learning
from PSEs Organizational leadership, fear of repercussion, training,
inter-organizational linkages, and ease of report systems These factors greatly influence learning from
Major event dissemination moderate events, minor events, and near misses
To improve patient safety, management may want to consider
Foster patient safety culture, provide training opportunities, and share information with other hospitals
Next Steps
LeadershipSafety
Culture
Group diversity
Group norms
Inter-organizational-Level Factors
Organization-Level Factors
Unit-Level Factors
Span of controlUnit leadershipInter-unit linkage
SaliencePerceived PLE Characteristics
Level of response to
PLE Unit
Organization
Inter-organizational
networks
Org size