An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety

Reliability Engineering and System Safety

Volumn 144, Issue , 2015, Pages 45-52

  Sujan, Mark ^a  

^a UNIVERSITY OF WARWICK   (United Kingdom)

Author keywords

Healthcare; Incident reporting; Organisational learning; Patient safety; Resilience

Indexed keywords

HEALTH CARE; INFORMATION MANAGEMENT; KNOWLEDGE MANAGEMENT;

HEALTH CARE PROFESSIONALS; HEALTHCARE ORGANISATIONS; INCIDENT REPORTING; NATIONAL HEALTH SERVICES; ORGANISATIONAL LEARNING; PATIENT SAFETY; RESILIENCE; SEMI STRUCTURED INTERVIEWS;

SAFETY ENGINEERING;

EID: 84938388613     PISSN: 09518320     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ress.2015.07.011     Document Type: Article

References (37)

1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry; 2013.
2. National Advisory Group on the Safety of Patients in England A promise to learn - a commitment to act 2013 Department of Health London
3. J Reason Managing the risks of organizational accidents 1997 Ashgate Farnham
4. JS Carroll, and AC Edmondson Leading organisational learning in health care Qual Saf Health Care 11 2002 51 56
5. C Argyris, and DA Schön Organisational learning II: theory, method and practice 1996 Addison-Wesley Reading, MA
6. M Popper, and R Lipshitz Organizational learning mechanisms a structural and cultural approach to organizational learning J Appl Behav Sci 34 1998 161 179
7. C Billings Incident reporting systems in medicine and experience with the aviation reporting system RI Cook, D Woods, CA Miller, A tale of two stories: contrasting views of patient safety 1998 US National Patient Safety Foundation North Adams, MA 52 61
8. CA Vincent Analysis of clinical incidents: a window on the system not a search for root causes Qual Saf Health Care 13 2004 242 243
9. Department of Health An organisation with a memory 2000 The Stationary Office London
10. JE Anderson, N Kodate, R Walters, and A Dodds Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting Int J Qual Health Care 25 2013 141 150
11. P Barach, and SD Small Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems BMJ 320 2000 759 763
12. A Hutchinson, TA Young, KL Cooper, A McIntosh, JD Karnon, S Scobie, and et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the national reporting and learning system Qual Saf Health Care 18 2009 5 10
13. KG Shojania The frustrating case of incident-reporting systems Qual Saf Health Care 17 2008 400 402
14. JI Westbrook, L Li, EC Lehnbom, MT Baysari, J Braithwaite, R Burke, and et al. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system Int J Qual Health Care 27 2015 1 9
15. R Harrison, R Lawton, and K Stewart Doctors' experiences of adverse events in secondary care: the professional and personal impact Clin Med 14 2014 585 590
16. DM Ashcroft, C Morecroft, D Parker, and PR Noyce Likelihood of reporting adverse events in community pharmacy: an experimental study Qual Saf Health Care 15 2006 48 52
17. J Benn, M Koutantji, L Wallace, P Spurgeon, M Rejman, A Healey, and et al. Feedback from incident reporting: information and action to improve patient safety Qual Saf Health Care 18 2009 11 21
18. J Braithwaite, MT Westbrook, JF Travaglia, and C Hughes Cultural and associated enablers of, and barriers to, adverse incident reporting Qual Saf Health Care 19 2010 229 233
19. R Lawton, and D Parker Barriers to incident reporting in a healthcare system Qual Saf Health Care 11 2002 15 18
20. B Wilson, HL Bekker, and F Fylan Reporting of clinical adverse events scale: a measure of doctor and nurse attitudes to adverse event reporting Qual Saf Health Care 17 2008 364 367
21. A Pasquini, S Pozzi, L Save, and MA Sujan Requisites for successful incident reporting in resilient organisations E Hollnagel, J Paries, D Woods, J Wreathall, Resilience engineering in practice: a guidebook 2011 Ashgate Farnham 237 254
22. J Firth-Cozens, N Redfern, and F Moss Confronting errors in patient care: the experiences of doctors and nurses AVMA Med Leg J 10 2004 184 190
23. M Sujan, S Pozzi, and C Valbonesi Reporting and learning: from extraordinary to ordinary J Braithwaite, R Wears, E Hollnagel, Reconciling work-as-imagined with work-as-done 2016 Ashgate Farnham
24. M Sujan, and D Furniss Organisational reporting and learning systems: innovating inside and outside the box Clin Risk 21 2015 7 12
25. G Guest, KM MacQueen, and EE Namey Applied thematic analysis 2011 Sage Thousand Oaks
26. J Saldaña The coding manual for qualitative researchers 2009 Sage London
27. AB Sari, TA Sheldon, A Cracknell, A Turnbull, Y Dobson, C Grant, and et al. Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital Qual Saf Health Care 16 2007 434 439
28. Cook RI. The no reports (TM) campaign rationale, 2013, Resilience Health Care Learning Network Blog. Available from: (http://resiliencehealthcarelearningnetwork.ca/blog/the-no-reports-campaign-rationale) (accessed 23.07.2015)
29. JS Carroll, and B Fahlbruch "The gift of failure: new approaches to analyzing and learning from events and near-misses." Honoring the contributions of Bernhard Wilpert Saf Sci 49 2011 1 4
30. MA Sujan, C Ingram, T McConkey, S Cross, and MW Cooke Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions BMJ Qual Saf 20 2011 549 556
31. MA Sujan A novel tool for organisational learning and its impact on safety culture in a hospital dispensary Reliab Eng Syst Saf 101 2012 21 34
32. LM Goldenhar, PW Brady, KM Sutcliffe, and SE Muething Huddling for high reliability and situation awareness BMJ Qual Saf 22 2013 899 906
33. SJ Singer, and TJ Vogus Reducing hospital errors: interventions that build safety culture Annu Rev Public Health 34 2013 376 396
34. L Jeffs, W Berta, L Lingard, and GR Baker Learning from near misses: from quick fixes to closing off the Swiss-cheese holes BMJ Qual Saf 21 2012 287 294
35. E Hollnagel Why is work-as-imagined different from work-as-done? R Wears, E Hollnagel, J Braithwaite, Resilience of everyday clinical work 2015 Ashgate Farnham
36. C Macrae Reconciling regulation and resilience in health care E Hollnagel, J Braithwaite, R Wears, Resilient health care 2013 Ashgate Farnham 111 122
37. D Woods, and M Branlat Basic patterns how adaptive systems fail E Hollnagel, J Paries, D Woods, J Wreathall, Resilience engineering in practice: a guidebook 2011 Ashgate Farnham 127 143