From blaming to learning: re-framing organisational learning from adverse incidents.

Dee Gray; Sion Williams

Study

From blaming to learning: re-framing organisational learning from adverse incidents.

October 26, 2011

Gray D, Williams S. Learn Org. 2011;18(6):438-453.

View more articles from the same authors.

This study reports on an effort to use voluntary error reporting as a tool for teaching trainees about patient safety.

Available at

Related Resources From the Same Author(s)

Electronic prescribing within an electronic health record reduces ambulatory prescribing errors.

October 5, 2011

Professionalism: a necessary ingredient in a culture of safety.

January 30, 2005

A proposed approach to allegations of sexual boundary violation in health care.

December 13, 2023

Psychological safety and error reporting within Veterans Health Administration hospitals.

March 4, 2015

Random safety auditing, root cause analysis, failure mode and effects analysis.

May 19, 2010

Perinatal clinical decision support system: a documentation tool for patient safety.

October 10, 2007

Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.

December 12, 2007

Crisis resource management in emergency medicine.

March 7, 2012

Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.

April 5, 2023

Patient safety and interprofessional education: a report of key issues from two interprofessional workshops.

May 3, 2017

Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care.

October 29, 2014

Antiretroviral medication errors in a national medication error database.

January 11, 2006

Patient misidentification in the neonatal intensive care unit: quantification of risk.

January 18, 2006

'I think this medicine actually killed my wife': patient and family perspectives on shared decision-making to optimize medications and safety.

July 17, 2019

Changing experience of adverse medical events in the National Health Service: comparison of two population surveys in 2001 and 2013.

February 14, 2018

Coupling policymaking with evaluation—the case of the opioid crisis.

December 20, 2017

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

Broadening the concept of patient safety culture through value-based healthcare.

August 18, 2021

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

October 25, 2006

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.

April 4, 2012

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study.

May 25, 2022

Exploring the role of communications in quality improvement: a case study of the 1000 Lives Campaign in NHS Wales.

May 27, 2015

Are quality improvement collaboratives effective? A systematic review.

January 10, 2018

Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency department visits following an outpatient visit at risk for diagnostic error: a retrospective cohort study using medicare claims.

April 14, 2021

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

November 17, 2021

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis.

October 5, 2022

The $17.1 billion problem: the annual cost of measurable medical errors.

April 20, 2011

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

March 29, 2012

Emergency department checklist: an innovation to improve safety in emergency care.

October 31, 2018

Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture (SOPS) Workplace Safety Supplemental Items for Hospitals.

June 29, 2022

Checklists for assessment and certification of clinical procedural skills omit essential competencies: a systematic review.

April 2, 2008

The link between clinically validated patient safety indicators and clinical outcomes.

January 10, 2018

Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities.

October 29, 2014

Experiences of transgender and gender nonbinary patients in the emergency department and recommendations for health care policy, education, and practice.

July 21, 2021

Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson disease.

October 24, 2018

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City.

July 29, 2020

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.

March 26, 2008

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

January 31, 2007

Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

June 4, 2008

Improving patient safety by practicing in a just culture.

July 12, 2017

Safe and appropriate use of insulin and other antihyperglycemic agents in hospital.

April 23, 2014

'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.

December 6, 2023

Accidents, claiming, and regional subcultures: are medical errors and malpractice lawsuits related to social capital?

July 9, 2008

Improving patient safety in radiotherapy by learning from near misses, incidents and errors.

August 1, 2007

Unsafe care in residential settings for older adults. A content analysis of accreditation reports.

December 13, 2023

A case for safety leadership team training of hospital managers.

March 2, 2011

Meaningful use of health information technology and declines in in-hospital adverse drug events.

March 8, 2017

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

November 11, 2009

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

January 9, 2019

Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.

December 21, 2011

Measure twice, cut once.

July 24, 2013

Professionalism lapses and adverse childhood experiences: reflections from the island of last resort.

August 14, 2019

Changing our culture: adopting the military aviation safety system.

July 16, 2014

Patient Safety and Quality Improvement Act of 2005.

May 10, 2006

Malpractice liability, patient safety, and the personification of medical injury: opportunities for academic medicine.

September 13, 2006

The physician's role in patient safety: what's in it for me?

February 13, 2008

Use of critical incident reports in medical education: a perspective.

November 16, 2005

Inside a closed-loop medication strategy: medication management targets stages in which errors occur, step by step.

March 6, 2005

Adverse outpatient drug events—a problem and an opportunity.

March 6, 2005

Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.

July 27, 2005

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

Maths anxiety and medication dosage calculation errors: a scoping review.

October 12, 2016

Health information technology and its effects on hospital costs, outcomes, and patient safety.

October 24, 2012

Making electronic health records both SAFER and SMARTER.

July 27, 2022

Evaluation of a healthcare safety climate measurement tool.

December 17, 2008

Medical students' experiences with medical errors: an analysis of medical student essays.

June 11, 2008

Scientific inquiry. 100,000 lives campaign and the application to children.

May 3, 2006

The development of the National Reporting and Learning System in England and Wales, 2001-2005.

June 7, 2006

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

Wide variation and overprescription of opioids after elective surgery.

October 11, 2017

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: a scoping review.

January 24, 2024

Surgeons in difficulty: an exploration of differences in assistance-seeking behaviors between male and female surgeons.

October 14, 2015

Determination of health-care teamwork training competencies: a Delphi study.

December 2, 2009

Patient safety and medical liability: current status and an agenda for the future.

September 8, 2010

An implementation strategy for a multicenter pediatric rapid response system in Ontario.

June 9, 2010

Physician health and wellbeing provide challenges to patient safety and outcome quality across the careerspan.

April 13, 2016

Caught in the middle: a resident perspective on influences from the learning environment that perpetuate mistreatment.

March 23, 2016

The "hidden curriculum" and residents' attitudes about medical error disclosure: comparison of surgical and nonsurgical residents.

October 9, 2013

Every patient should be enabled to stop the line.

December 12, 2018

Opioid medication discontinuation and risk of adverse opioid-related health care events.

June 12, 2019

Back to basics: checklists in aviation and healthcare.

June 17, 2015

A model of disruptive surgeon behavior in the perioperative environment.

October 15, 2014

Narrative review: do state laws make it easier to say "I'm sorry"?

December 17, 2008

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

August 6, 2008

Hospital finances and patient safety outcomes.

June 15, 2005

Fixing broken bones and broken homes: domestic violence as a patient safety issue.

March 6, 2005

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.

November 25, 2015

Putting the 'patient' in patient safety: a qualitative study of consumer experiences.

June 15, 2011

Improving patient safety in radiation oncology.

March 16, 2011

Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?

September 23, 2009

The impact of resident duty hour and supervision changes: a review.

December 9, 2015

Obstetric safety and quality.

August 26, 2015

Making healthcare safer by understanding, designing and buying better IT.

July 22, 2015

When doing wrong feels so right: normalization of deviance.

March 25, 2015

Paramedics and the effects of shift work on sleep: a literature review.

February 29, 2012

Examining the diagnostic justification abilities of fourth-year medical students.

November 7, 2012

Interventions to reduce medication errors in adult intensive care: a systematic review.

September 26, 2012

Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.

August 15, 2012

Organizational response to known medical errors: does peer review protection impede improvement?

May 30, 2018

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Learning Health Systems

January 1, 2023

Patient Safety Incident Response Framework.

August 31, 2022

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

Benefits of reporting and analyzing nursing students' near-miss medication incidents.

March 9, 2022

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.

May 5, 2021

Hearing impairment and the amelioration of avoidable medical error: a cross-sectional survey.

April 28, 2021

Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

March 31, 2021

Health professionals' perspectives of safety issues in mental health services: a qualitative study.

March 31, 2021

Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care.

March 24, 2021

Dispensing Errors.

December 16, 2020

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system.

September 9, 2020

Participation in a system-thinking simulation experience changes adverse event reporting.

July 8, 2020

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

April 1, 2020

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service

February 19, 2020

Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons.

August 28, 2019

How medical error shapes physicians' perceptions of learning: an exploratory study.

August 21, 2019

Beyond the clinical team: evaluating the human factors-oriented training of non-clinical professionals working in healthcare contexts.

July 17, 2019

The attitudes of nursing students and clinical instructors towards reporting irregular incidents in the medical clinic.

June 5, 2019

The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

May 15, 2019

Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study.

May 1, 2019

Is physician mentorship associated with the occurrence of adverse patient safety events?

April 10, 2019

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

April 1, 2019

Essential activities for electronic health record safety: a qualitative study.

March 20, 2019

Improving resident and fellow engagement in patient safety through a graduate medical education incentive program.

January 23, 2019

Using patient safety reporting systems to understand the clinical learning environment: a content analysis.

January 9, 2019

Benefactor or burden: exploring the professional identity of safety professionals.

October 24, 2018

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

See More About The Topic

Quality and Safety Professionals

Educators

Institutional Reporting

Learning Organization

Education and Training

From blaming to learning: re-framing organisational learning from adverse incidents.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

From blaming to learning: re-framing organisational learning from adverse incidents.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site