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

Event Types

Quick comparison

0

0.5

1

1.5

2

2.5

3

3.5

4

Minor Events Major Events

Today

Survey 3 years ago

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

Next Step

File out USB keys Please leave mailing addresses with

us Pilot of unit-level learning

THANK YOU!