What Factors Influence
Learning from PSEs?
Research Team:
Liane Ginsburg, You-Ta Chuang
Peter 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




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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
4
3.5
3
2.5
Today
2
Survey 3 years ago
1.5
1
0.5
0
Minor Events
Major Events
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
Learning scores
4
Major event
analysis (no effect)
3.5
Major event
dissemination
Moderate events
3
Minor events
2.5
Major near misses
2
2.43
4.93
Organizational leadership for patient safety
Fear of repercussion
Learning scores
4
Major event analysis
(no effect)
3.5
Major event
dissemination
Moderate events
3
Minor events
2.5
Major near misses
2
High
Fear of repercussion
Low
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
Learning scores
4
Major event
analysis (no
effect)
3.5
Major event
dissemination
3
Moderate
events
2.5
Minor events
2
Major near
misses
1.5
0
PCM training
3
4. Effects of Interorganizational Linkages


Inter-organizational linkages facilitate information and
experience transfer; as such they help organizations learn
from others’ experiences.
Item in the PSO survey:


The linkages tend to be:



Please list the hospitals/organizations you frequently engage in
discussion or information sharing regarding patient safety
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
Learning scores
4.5
Major event
analysis
4
Major event
dissemination
3.5
Moderate events
3
Minor events (no
effect)
2.5
Major near misses
(no effect)
2
0
10
Inter-organizational linkages
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
Learning scores
4
3.5
Great fear of
repercussion
3
Little fear of
repercussion
2.5
2
Difficulty of reporting
Ease of reporting
Reporting
Minor events
Learning scores
3
2.75
Great fear of
repercussion
2.5
Little fear of
repercussion
2.25
2
Difficulty of reporting
Reporting
Ease of reporting
Summary/Implications

Factors at organizational level influence learning from
PSEs


Organizational leadership, fear of repercussion, training, interorganizational 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
Span of control
Group diversity
Unit leadership
Group norms
Inter-unit linkage
Salience
Org size Leadership
Safety Culture
Inter-organizational
networks
Unit-Level Factors
Perceived PLE
Characteristics
Organization-Level
Factors
Inter-organizationalLevel Factors
Level of response
to PLE
Unit
Organization
Next Step

File out USB keys

Please leave mailing addresses with us

Pilot of unit-level learning
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THANK YOU!