Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations.

Abstract

Purpose: Despite robust quality improvement efforts in healthcare, learning from patient safety incidents remains difficult. Our study explores counter-vailing powers shaping learning processes and possibilities in healthcare organizations, with a focus on social, political and organizational dynamics of learning.

Design/methodology/approach: Deploying concepts of situated curriculum, boundary work and interconnected knowledge practices, we interviewed staff and physicians (n = 15) in a large Academic Health Science Centre in Canada about their experiences of incident investigations and resultant information sharing. Our analytical strategy was abductive, drawing connections to sociology of the professions and learning sciences literature.

Findings: Incident investigation and follow-up processes are relatively robust for learning about incidents in the organization. However, learning from incidents remains difficult, complicated by the professional politics of incident classification, counter-vailing policies related to privacy, the organization of improvement work towards reporting, and an organizational focus on incidents with severe outcomes.

Practical implications: Participants advocated for a broader view of incidents, moving beyond classification and investigation based on severity of outcome to also include incidents that are "learning rich". To that end, we argue for more research on the role of Patient Safety Specialists in organizational learning and more collaborations with learning sciences.

Originality/value: This paper illuminates ways in which robust information dissemination structures are an important but insufficient condition for learning from incidents. The argument goes beyond a prescriptive approach to learning from incidents to instead explore the competing visions and values implicated with improvement practices.