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  5. Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness
 
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Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness

Author(s)
Anderson, Janet E.  
Kodate, Naonori  
Uri
http://hdl.handle.net/10197/7439
Date Issued
2015-12
Abstract
Learning from patient safety incidents is difficult; information is often incomplete, and it is not clear which incidents are preventable or which intervention strategies are optimal. Effective group processes are vital for learning but few studies in healthcare have examined in depth the processes involved and whether they are effective. The aims of this study were to identify factors that facilitated and hindered the process of analysing incidents in teams and to develop and apply a framework of indicators of effective analytic processes. Incident review meetings in acute care and mental health care were observed. Full field notes were analysed thematically. A framework of process measures was developed and used to rate each meeting using the field notes. Reliability was analysed. Factors hindering analysis were lack of organisational support, high workload and a managerial, autocratic leadership style. Facilitating factors were participatory interactions and strong safety leadership. Process measures showed deficits in critiquing the causes of incidents, seeking further information, critiquing potential solutions and solving problems that crossed organisational boundaries, supporting observational data on the importance of effective leadership. Organisational legitimacy, administrative support, training, tools for incident analysis, effective well trained leaders who empower the team and sufficient resources to manage the high workload were all identified in this study as necessary changes to improve learning. Future studies could develop and validate the proposed framework of process indicators to provide a tool for teams to use as an aid to improve the analysis of incidents.
Other Sponsorship
National Institute for Health Research (NIHR)
Type of Material
Journal Article
Publisher
Elsevier
Journal
Safety Science
Volume
80
Start Page
105
End Page
114
Copyright (Published Version)
2015 Elsevier
Subjects

Incident reporting

Organisational learni...

Leadership

Patient safety

Incident review meeti...

Safety leadership

DOI
10.1016/j.ssci.2015.07.012
Language
English
Status of Item
Peer reviewed
This item is made available under a Creative Commons License
https://creativecommons.org/licenses/by-nc-nd/3.0/ie/
File(s)
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SafSci_anderson&kodate_2015_Repository.docx

Size

69.71 KB

Format

Microsoft Word

Checksum (MD5)

f92ec8621ade7e875b173d88403f5873

Owning collection
Social Policy, Social Work and Social Justice Research Collection

Item descriptive metadata is released under a CC-0 (public domain) license: https://creativecommons.org/public-domain/cc0/.
All other content is subject to copyright.

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