Learning to Learn From Patient Safety EventsKnowledge Exchange Workshop, Nov. 2nd, 2010 gWinnipeg Regional Health Authority fResearch funded by the Canadian Institutes of Health ResearchMeasuring Learning at the Patient Care Unit Level
OutlinePSE Learning study summaryCan we only learn from Catastrophe?Is there variation in learning from PSEs across Ontario hospitals?What factors influence PSE learning?
1. Learning from Patient Safety EventsStudy Background 3-year, 2-phase study:P1. To understand what kind of PSEs are relevant to staff and managers in daily practiceP1. Develop PSE Learning InstrumentP2. What factors influence learning from PSEs
to err is humanto cover up is unforgivableto fail to learn is inexcusable-Sir Liam Donaldson Chief Medical Officer UK Department of Health
IdentificationIdentify and bring PSEs to the attention of others The universe of PSEsDimensions of PSE LearningRoots: theoretical models of learning from failure (Argote 1999AnalysisChangeProperly analyze the system-level causes of PSEs Put corrective strategies in place to reduce PSE reoccurrence; monitor change to ensure its sustained Smaller numbers of PSEs subject to each stage of the learning processBased on Failure-induced learning theory: Sasou, K., and J. Reason. 1999. Team Errors: Definition and Taxonomy. Reliability Engineering and System Safety, 65 (1): 19. Argote, L. 1999. Organizational Learning: Creating, Retaining and Transferring Knowledge. Norwell: Kluwer.Dissem-inationCommunicate and disseminate information learned above to others on the unit / in the organization
Matryoshka Dolls Learning from patient safety events takes place in only a very small subset of events
A1. Safety incidents2. Recognized safety incidents3. Recognized and discussed incidents5. Recognized, and locally investigatedBC4. Recognized, discussed and reported:A in the chartB to a paper or on-line IR systemC to person / team with mandate & resources to investigate and make change
But we learn differently from different types of PSEsThe following typology:Emerged from focus groups with front-line staff and managersDescribes how these front-line groups naturally group PSEsSeen as meaningful for understanding everyday practice
Definition:An event involving no harm or very minimal temporary harm to the patient.
Examples:Administering Extra-strength Tylenol instead of Tylenol 2s; a missed suppository and patient suffers one day of mild constipation; staff forgets patients appointment for seating servicing and a patient must wait another week for a new chairDefinition:An event that causes discomfort sufficient to interfere with usual activity and requires additional specific therapeutic intervention but, poses no significant or permanent risk of harm to the patient.
Examples:Post stroke patient on dysphagic diet is given thin fluids and aspirates resulting in pneumonia, resolves with treatment Definition:An event involving death or serious physical / psychological injury. These events should not be considered stuff that just happens. Nor should they be considered inevitable.
Examples:Unanticipated death or major permanent loss of function; suicide; hemolytic transfusion reaction involving administration of blood; surgery on the wrong patient or wrong body part. Definition:An event that would have resulted in death or serious physical or psychological injury but did not because it was caught or because of good luck.
Examples:Interrupted attempted suicide by hanging, wrong patient is sent for a surgical procedure and is discovered in the OR Definition:An event that would have resulted in no harm or very minimal temporary harm to the patient but did not because it was caught or because of good luck.
Examples:Noticing that you have dispensed extra-strength Tylenol when Tylenol 2 was ordered
Typology of Patient Safety Events Events can cause varying degrees of harm from none to very severe
Practically speakingthe goal is to grow the size of the smallest matryoshka doll and also recognize that we learn differently from different types of PSEsFor minor events, the largest matryshka doll (the universe of events) would be enormous and the smallest (Actual learning) would be tiny
The PSE Learning Checklist
Concrete set of learning behaviours that can function as a checklist following different types of PSEs that are identified
What learning behaviors do we engage in most oftenleast often?
% engaging in learning response always/almost always OR usually
% engaging in learning response always/almost always OR usually
Support at all Levels- Squeezed in the middle- In our experience, most boards and leaders overestimate the frontline staffs ability to improve. In such cases, even with sufficient will and great ideasexecution stalls (Conway, 2008) Single-loop learning quick fixes Double-loop learning correcting the underlying causes of a problem
2. Can we only learn from Catastrophe?
1.Can we only learn from Catastrophe?Learning Responses to 4 types of PSEs4-Always
n=54Event learningEvent learningEvent learning
3. Is there variation in learning from PSEs across hospitals?
Minor event learning scores for 54 Ontario hospitals4-Always
Major event Analysis learning scores for 54 Ontario hospitals4-Always
Major event Dissemination learning scores for 54 Ontario hospitals4-Always
4. What factors influence learning from Patient Safety Events?
Factors that influence learning from PSEsFunctional diversity of the unit (invU-shape)Type of PSEsManager PS trainingInter-organizational linkagesPsychological safety & fear of repercussionsEase of reporting (+ with low fear only)Formal organizational leadership for PS ++
Organizational Leadership for PS and Learning from PSEs
Soin 3 years we found outPractically speaking F-L staff and managers think in terms of straightforward, pretty clear cut event typesThere are a series of concrete learning responses that organizations and units can and should be engaging in to reduce reoccurrence of PSEs But the complete learning process is found only in the smallest Matryoshka dollWe do more in response to catastrophesBut some organizations do a lot more than othersAnd we can identify some factors that learning
Using PSE Learning ChecklistComparison over timeStarting conversations Do the PSE learning instrument with the right people: assess current practiceTake the results (and process?) up and down the organization: goal settingGetting CEOs involved through an in-depth PSE case study (Conway, 2008)PSE Learning instrument concrete tool to reduce the knowing-doing gap (Pfeffer & Sutton, 2000): action reduces this gap
ReferencesGinsburg, L., Y. Chuang, P.G. Norton, W. Berta, D. Tregunno, P. Ng, J. Richardson. (2010). The relationship between organizational leadership for safety and learning from patient safety failure events. Health Services Research. [Epub ahead of print]Ginsburg, L., Y. Chuang, P.G. Norton, W. Berta, D. Tregunno, P. Ng, J. Richardson. (2009) Development of a Measure of Patient Safety Event Learning Responses. Health Services Research. 44(6): 2123-2147..Ginsburg, L.R., Y. Chuang, J. Richardson, P.G. Norton, W. Berta, D. Tregunno, P. Ng. Categorizing Errors and Adverse Events for Learning: The provider perspective. (2009) Healthcare Quarterly, 12:154-160.Chuang, Y., Ginsburg, L., Berta, W. (2007). Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions. Health Care Management Review, 32(4).http://www.yorku.ca/patientsafety/
This is big process intensive stuff
Describe this work brieflyReverse coded so higher learning score is better, unlike in the reportInter-organizational linkages facilitate information and experience transfer; as such they help organizations learn from others experiences.Ease of reporting exerts a fairly strong influence on learning PROVIDED THAT there is low fear of repercussions
Learning scores when formal org leadership for safety is perceived to be low (LEFT)Learning scores when formal org leadership for safety is perceived to be strong (RIGHT)