Learning from Patient Safety Failures
in Acute Care Hospitals in Ontario: Study Overview

location: MainLearning from Errors

This study recognizes that, despite our best efforts, patient safety failure events will always occur in hospitals. Accordingly, we focus on how organizations can learn from different types of patient safety events that occur so that reoccurrence of similar events can be reduced.

Project Objectives

This three-year, two-phase study used a mixed methods approach. The key objectives of the research were:
(1) In Phase 1, to refine and validate a typology of Patient Safety Events that is meaningful to front-line staff and managers and to develop a typology of responses to these events
(2) In Phase 2, to investigate the influence of various factors (at the unit, organizational, and inter-organizational levels) on learning from patient safety events at the organization level in acute care hospitals

What Do We Mean by Learning?

Learning is defined in terms of appropriate responses to patient safety failure events. It includes actions to identify and report failures, analyze their causes, identify and implement changes to reduce their reoccurrence, and disseminate learnings to staff across the organization. This definition of learning is adapted from definitions of learning from failure used in the broader organizational literature (e.g. Argote, 1999)

Study Context:
Learning in relation to patient safety failure events in acute care hospitals in Ontario

Focus:
Factors that influence learning responses to patient safety failure events

Target Sample:
Acute care hospitals in Ontario, Canada

Study Outcomes:
	Phase 1: Identification of types of patient safety events that are meaningful to front-line staff and managers in hospitals; identification of appropriate learning responses for different types of patient safety events (from minor events to major events and major near misses). Timelines: completed in 2006 [see Publications]
	Phase 2: identification of factors that influence learning from these types of patient safety events in acute care hospitals. Timelines: completed in 2008 [see Publications]

Explore Phases One and Two in detail here.

Acknowledgements This research is funded by the Canadian Institutes of Health Research (CIHR) through the Knowledge Translation Strategies for Health Research Strategic Initiative. Liane Ginsburg is also supported by a Ministry of Health & Long Term Care Career Scientist Award.

This page was updated on March 01 2010.