Skip Navigation
The Collection >
Development of a measure of patient safety event learning responses.
Ginsburg LR, Chuang YT, Norton PG, et al. Health Serv Res. 2009;44:2123-2147.

Voluntary error reporting systems have many limitations, ranging from selection bias in reporting to a perception that errors may not be appropriately addressed. A 2008 survey found that only a minority of US hospitals had a structured system for following up on reported events. This mixed-methods study used a combination of surveys, focus groups, and expert panels to define measurements for how organizations respond to patient safety events. The authors defined a set of indicators that evaluate the analysis of the event and the dissemination of learnings from the event. Failure to appropriately address reported errors contributes to normalization of deviance, a "culture of low expectations" that has been implicated in high-profile errors.

PubMed citation icon indicating hyperlink to external website
Available at icon indicating hyperlink to external website
white box
Related Resources
AUDIOVISUAL
Healthcare 411: medication safety toolkit.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
STUDY
Using prospective clinical surveillance to identify adverse events in hospital.
Forster AJ, Worthington JR, Hawken S, et al. BMJ Qual Saf. 2011;20:756-763.
BOOK/REPORT
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
STUDY
Predicting patient complaints in hospital settings.
Kline TJB, Willness C, Ghali WA. Qual Saf Health Care. 2008;17:346-350.
View all related resources...
white box
Download: Adobe Reader   email icon Email
tan box
Find Related Resources by...
Resource Type   
 style=
Setting of Care  
 style=
Target Audience  
 style=
Clinical Area  
 style=
Approach to Improving Safety  
 style=
Origin/Sponsor  
white box