Learning from preventable adverse events in health care organizations: Development of a multilevel model of learning and propositions

Health Care Management Review

Volumn 32, Issue 4, 2007, Pages 330-340

  Chuang, You Ta ^a   Ginsburg, Liane ^b   Berta, Whitney B ^c,d  

^a YORK UNIVERSITY   (Canada)

^b York University   (Canada)

^c Health Services Organization and Management   (Canada)

^d UNIVERSITY OF TORONTO   (Canada)

Author keywords

Organizational learning; Preventable adverse events

Indexed keywords

ADVERSE OUTCOME; DYNAMICS; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; LEADERSHIP; LEARNING; REVIEW; THEORETICAL MODEL; THEORETICAL STUDY;

CLINICAL COMPETENCE; DECISION MAKING, ORGANIZATIONAL; HEALTH PERSONNEL; HUMANS; IATROGENIC DISEASE; LEADERSHIP; LEARNING; MEDICAL ERRORS; MODELS, EDUCATIONAL; ORGANIZATIONAL CULTURE; ORGANIZATIONAL INNOVATION; QUALITY ASSURANCE, HEALTH CARE; SAFETY MANAGEMENT; STAFF DEVELOPMENT;

EID: 37349022418     PISSN: 03616274     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.HMR.0000296790.39128.20     Document Type: Review

References (67)

1. Argote, L. (1999). Organizational learning: Creating, retaining and transferring knowledge. Norwell, MA: Kluwer Academic Publishers.
2. Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., et al. (2004). The Canadian Adverse Events Study: The incidence of adverse events in hospitalized patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686.
3. Bandura, A., & Cervone, D. (1983). Self-evaluative and self-efficacy mechanisms governing the motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017-1028.
4. Bates, D. W., Cullen, D. J., Laird, N., Petersen, L. A., Small, S. D., Servi, D., et al. (1995). Incidence of adverse drug events and potential adverse drug events: Implications for prevention. Journal of the American Medical Association, 274(1), 29-34.
5. Burns, L. R., & Wholey, D. R. (1993). Adoption and abandonment of matrix management programs: Effects of organizational characteristics and interorganizational networks. Academy of Management Journal, 36, 106-138.
6. Canadian Broadcasting Corporation. (2003). Children's cancer trial went ahead without Health Canada approval. Retrieved January 15, 2005, from http://www.cbc.ca/story/canada/national/2003/06/12/cancer_trial030611.html
7. Chuang, Y. T., & Baum, J. A. C. (2003). It's all in the name: Failure-induced learning by multiunit chains. Administrative Science Quarterly, 48(1), 33-59.
8. Crossan, M. M., Lane, H. W., & White, R. E. (1999). An organizational learning framework: From intuition to institution. Academy of Management Review, 24, 522-537.
9. Cyert, R. M., & March, J. (1992). A behavioral theory of the firm. Cambridge, MA: Blackwell Publishers.
10. Darr, E. D., Argote, L., & Epple, D. (1995). The acquisition, transfer, and depreciation of knowledge in service organizations: Productivity in franchises. Management Science, 41, 1750-1762.
11. Davies, H. T. O., Nutley, S. M., & Mannion, R. (2000). Organisational culture and quality of health care. Quality in Health Care, 9, 111-119.
12. Department of Health. (2000). An organisation with a memory: Report of an expert group on learning from adverse events in the NHS Chaired by the Chief Medical Officer. London: The Stationery Office. Retrieved July 10, 2003, from http://www.doh.gov.uk/orgmemreport/
13. Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(4), 350-383.
14. Edmondson, A. C. (2002). The local and variegated nature of learning in organizations: A group-level perspective. Organization Science, 13(2), 128-146.
15. Edmondson, A. C. (2004). Learning from failure in health care: Frequent opportunities, pervasive barriers. Quality and Safety in Health Care, 13(Suppl. 2), ii3.
16. Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O'Shaughnessy, J., et al. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality & Safety in Health Care, 15(1), 39-43.
17. Firth-Cozens, J. (2001). Cultures for improving patient safety through learning: The role of teamwork. Quality and Safety in Health Care, 10, ii26-ii31.
18. Fiske, S. T., & Taylor, E. T. (1991). Social cognition. New York: McGraw-Hill.
19. Friedman, V. J. (2001). The individual as agent of organizational learning. In M., Dierkes, B. A., Antal, J., Child, & I., Nonaka (Eds.), Handbook of organizational learning and knowledge (pp. 398-414). Oxford, NY: Oxford University Press.
20. Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. Journal of American Medical Association, 289, 1001L-1007L.
21. Gibson, C. B., & Vermeulen, F. (2003). A healthy divide: Subgroups as a stimulus for team learning behavior. Administrative Science Quarterly, 48, 202-239.
22. Ginsburg, L. (2003). Factors that influence line managers' perceptions of hospital performance data. Health Services Research, 38(1), 261-286.
23. Ginsburg, L., Norton, P. G., Lewis, S., & Casebeer, A. (2005). An educational intervention to enhance nurse leader perceptions of patient safety culture. Health Services Research, 40(4), 997-1020.
24. Haunschild, P. R., & Sullivan, B. N. (2002). Learning from complexity: Effects of prior accidents and incidents on airlines' learning. Administrative Science Quarterly, 47(4), 609-643.
25. Hayward, R. A., & Hofer, T. P. (2001). Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. Journal of American Medical Association, 286, 415-420.
26. Hoff, T., Jameson, L., Hannan, E., & Flink, E. (2004). A review of the literature examining linkages between organizational factors, medical errors, and patient safety. Medical Care Research and Review, 61, 3-37.
27. Huang, D. T., Clermont, G., Sexton, J. B., Karlo, C. A., Miller, R. G., Weissfeld, L. A., et al. (2007). Perceptions of safety culture vary across the intensive care units of a single institution. Critical Care Medicine, 35(1), 165-176.
28. Institute of Medicine. (2004). Patient Safety: Achieving a new standard for care. Washington, DC: National Academy Press.
29. Janis, I. L. (1982). Group think: Psychological studies of policy decisions and fiascoes. Boston, MA: Houghton Mifflin.
30. Jehn, K. A., Northcraft, G. B., & Neale, M. A. (1999). Why differences make a difference: A field study of diversity, conflict, and performance in workgroups. Administrative Science Quarterly, 44, 741-763.
31. Kohn, L. T., Corrigan, J., Donaldson, M. S., & Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.
32. Leana, C. R. (1985). A partial test of Janis' group think model: Effects of group cohesiveness and leader behavior on defective decision making. Journal of Management, 11, 5-17.
33. Leape, L. L., Woods, D. D., Hatlie, J., Kizer, K. W., Schroeder, S. A., & Lundberg, G. D. (1998). Promoting patient safety by preventing medical error. Journal of the American Medical Association, 280(16), 1444-1447.
34. Levitt, B., & March, J. G. (1988). Organizational learning. Annual Review of Sociology, 14, 319-340.
35. Longo, D. R., Hewett, J. E., Ge, B., & Schubert, S. (2005). The long road to patient safety: A status report on patient safety systems. Journal of the American Medical Association, 294, 2858-2865.
36. March, J. G., Sproull, L. S., & Tamuz, M. (1991). Learning from samples of one or fewer. Organization Science, 2, 1-13.
37. Miner, A. S., Kim, J.-Y., Holzinger, I. W., & Haunschild, P. R. (1999). Fruits of failure: Organizational failure and population-level learning. Advances in Strategic Management, 16, 187-220.
38. Mohr, J. J., Abelson, H. A., & Barach, P. (2002). Creating effective leadership for improving patient safety. Quality Management in Health Care, 11(1), 69-78.
39. Mohr, J. J., & Batalden, P. B. (2002). Improving safety on the front lines: The role of clinical microsystems. Quality and Safety in Health Care, 11(1), 45-50.
40. Nieva, V. F., & Sorra, J. (2003). Safety culture assessment: A tool for improving patient safety in healthcare organizations. Quality and Safety in Health Care, 12, 17ii-23ii.
41. Nisbett, R. E., & Ross, L. (1980). Human inference: Strategies and shortcomings of social judgment. Englewood Cliffs, NJ: Prentice-Hall.
42. Nonaka, S., & Takeuchi, N. (1995). The knowledge creating company. New York: Oxford University Press.
43. Oh, H., Chung, M. -H., & Labiance, G. (2004). Group social capital and group effectiveness: The role of informal socializing ties. Academy of Management Journal, 47, 860-875.
44. Pisano, G., Bohmer, R., & Edmondson, A. C. (2001). Organizational differences in rates of learning: Evidence from the adoption of minimally invasive cardiac surgery. Management Science, 47, 752-768.
45. Reagans, R., & McEvily, B. (2003). Network structure and knowledge transfer: The effects of cohesion and range. Administrative Science Quarterly, 48, 240-267.
46. Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, Hants, England: Ashgate.
47. Rivard, P. E., Rosen, A. K., & Carroll, J. S. (2006). Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction? Health Services Research, 41(4 Pt. 2), 1633-1653.
48. Rosenthal, M. M., & Sutcliffe, K. M. (2002). Struggling to understand, struggling to act. In M. M., Rosenthal, & K. M., Sutcliffe (Eds.), Medical error: What do we know, what do we do (pp. 237-265). San Francisco: Jossey-Bass.
49. Runciman, W. B., & Moller, J. (2001). Iatrogenic injury in Australia. Adelaide, SA:Australian Patient Safety Foundation.
50. Sadler, P. (2001) Leadership and organizational learning. In D., Meinolf, A., Berthoin Antal, J., Child, & I., Nonaka (Eds.), Handbook of organizational learning and knowledge (pp. 415-427). Oxford, NY: Oxford University Press.
51. Sasou, K., & Reason, J. (1999). Team errors: Definition and taxonomy. Reliability Engineering and Safety, 65, 1-9.
52. Schweiger, D., Sandberg, W., & Ragan, J. (1986). Group approaches for improving strategic decision making: A comparative analysis of dialectical inquiry, devil's advocacy, and consensus. Academy of Management Journal, 29, 51-71.
53. Sitkin, S. B. (1992). Learning through failure: The strategy of small losses. Research in Organizational Behavior, 14, 231-266.
54. Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J., & Bates, D. W. (2006). The "To Err is Human" report and the patient safety literature. Quality and Safety in Health Care, 15, 174-178.
55. Sutcliffe, K. M. (2004). Defining and classifying medical error: Lessons for learning. Quality and Safety in Health Care, 13, 8-9.
56. Szulanski, G. (2003). Sticky knowledge: Barriers to knowing in the firm. London: Sage.
57. Tamuz, M., Thomas, E. J., & Franchois, K. E. (2004). Defining and classifying medical error: Lessons for patient safety reporting systems. Quality and Safety in Health Care, 13, 13-20.
58. Tucker, A., & Edmondson, A. C. (2002). Managing routine exceptions: A model of nurse problem solving behavior. Advances in Health Care Management, 3, 87-113.
59. Tucker, A., & Edmondson, A. C. (2003). Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change. California Management Review, 45(2), 55-72.
60. Wald, H., & Shojania, K. G. (2001). Incident reporting and root cause analysis. In B. W., Duncan, K. M., McDonald, et al. (Eds.), Making health care safer: A critical analysis of patient safety practices. (Evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058. Prepared by the University of California at San Francisco - Stanford Evidence-based Practice Center under Contract No. 290-97-0013). Rockville, MD: Agency for Healthcare Research and Quality.
61. Walshe, K. (2003). Understanding and learning from organizational failure. Quality and Safety in Health Care, 12, 81-82.
62. Weick, K. E. (1979). The social psychology of organizing. Reading, MA: Addison-Wesley.
63. Williams, K. Y., & O'Reilly, C. A. (1998). Demography and diversity in organizations: A review of 40 years of research. Research in Organizational Behavior, 20, 77-140.
64. Wilson, R. L., Runciman, W. B., Gibberd, R. W., Harrison, B. T., Newby, L., & Hamilton, J. D. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia, 163, 458-471.
65. Westrum, R. (2004). A typology of organisational cultures. Quality and Safety in Health Care, 13(Suppl. 2), ii22-ii27.
66. Wu, A. W., Folkman, S., McPhee, S. J., & Lo, B. (1991). Do house officers learn from their mistakes? Journal of the American Medical Association, 265, 2089-2094.
67. Zohar, D., Livne, Y., Tenne-Gazit, O., Admi, H., & Donchin, Y. (2007). Healthcare climate: A framework for measuring and improving patient safety. Critical Care Medicine, 35(5), 1312-1317.