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Last Updated: May 6, 2024
Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
Description
Organizational learning is an environmental state that ensures lessons from lived experience within a work environment are coupled with data then fed into, and embedded within, the organization’s policies and culture to ensure continuous improvement and support collective high reliability. This curated library focuses on concepts and activities supporting learning at an overarching rather than individual level.
Library Organization
Custom - This library is organized by custom section header names.
Foundations (11)
Donaldson L. London, UK: The Stationery Office, 2000.
An Organisation with a Memory set out to understand what was known about the scale and nature of serious failures... Read More
Edmondson A. Harv Bus Rev. 2011;89:48-55, 137.
Failures are inevitable in any industry, especially in one as complex as health care. The ability to learn from failures is a crucial characteristic of high reliability organizations, and creating a climate... Read More
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American... Read More
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Implementation (6)
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;37:3965-3972.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United... Read More
Monazam Tabrizi N, Masri F. BMJ Open. 2021;11:e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to... Read More
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33:mzab046.
High reliability organizations consistently examine and learn from failures. This systematic review... Read More
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Safety II (1)
Arnal-Velasco D, Heras-Hernando V. Curr Opin Anaesthesiol. 2023;36:376-381.
The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review... Read More
Technology (4)
Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.
Analyzing patient safety incident reports is essential to organizational learning, but comes with both a time and financial burden. This study... Read More
Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.
Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning... Read More
Satterfield K, Rubin JC, Yang D, et al. Learn Health Syst. 2019;4:e210204.
The authors interviewed 32 individuals with expertise in learning health systems to explore how such systems can work towards... Read More
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All Library Content (22)
Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.
Analyzing patient safety incident reports is essential to organizational learning, but comes with both a time and financial burden. This study found that natural language processing can be used to process unstructured patient safety event reports and reduce the burden of manually identifying and extracting factors contributing to the event.
Arnal-Velasco D, Heras-Hernando V. Curr Opin Anaesthesiol. 2023;36:376-381.
The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review highlights recent research conducted within a Safety II and resilience framework such as Learning from Excellence and debriefing "what went right" after simulation training. The authors suggest learning from errors or what goes right should be reframed simply as learning.
Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.
Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning health systems can improve the safety of new technologies, such as hiring health informaticists and collaborations with health authorities and vendors.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;37:3965-3972.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Monazam Tabrizi N, Masri F. BMJ Open. 2021;11:e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33:mzab046.
High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.
ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4
In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom to illustrate the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.
Boston, MA: Institute for Healthcare Improvement: September 2020.
This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.
Lyman B, Biddulph ME, Hopper VG, et al. J Nurs Manag. 2020;28:1241-1249.
This study used semi-structured interviews with nurses to explore their experiences with organizational learning. Thematic analyses revealed that organizational learning was more effective when closely aligned with the Organisational Learning in Hospitals model and suggests that health system leadership and nurse managers play a central role in organizational learning.
Satterfield K, Rubin JC, Yang D, et al. Learn Health Syst. 2019;4:e210204.
The authors interviewed 32 individuals with expertise in learning health systems to explore how such systems can work towards diagnostic excellence. Data, management, and behavioral barriers are discussed, such as the need to standardize measurement, the need for measures that both define and track errors, and that clinicians lack tools to self-assess diagnostic skills. The authors discuss how machine learning and artificial intelligence can be leveraged to advance diagnostic excellence, but that any meaningful integration must be accomplished through mutually beneficial collaborations among researchers and care providers.
Newspaper/Magazine Article
Klenklen J. Patient Saf Qual HCare. December 19, 2019.
High reliability organizations consistently examine what goes wrong and remain aware that failure can happen at any time. This article discusses a learning model built upon event definition, rapid contributing factor identification, system-focused communication, and standardized learning to facilitate organizational learning from sentinel events.
Lyman B, Jacobs JD, Hammond EL, et al. J Adv Nurs. 2019;75:2352-2377.
Organizations are encouraged to learn from failures. This review synthesizes the research on organizational learning in hospitals, including contextual factors that affect it, how such learning occurs, and improvements implemented as a result.
Lyman B, Hammond EL, Cox JR. J Nurs Manag. 2019;27:633-646.
Organizations are encouraged to learn from failures and sustain improvement. This review defines the concept of organizational learning, characteristics of the activity, and the key attributes needed to support it. The authors summarize the role that nursing and organizational leaders play in creating an environment that supports learning to enhance performance.
Britto MT, Fuller SC, Kaplan HC, et al. BMJ Qual Saf. 2018;27.
The National Academy of Sciences has advocated for a Learning Healthcare System in which patients are engaged in shared decision-making to choose evidence-based, high-quality care. However, realizing the vision of a system that improves over time as a direct result of learning captured from patient care has proved challenging. This study describes the development and implementation of a network organizational model for learning health care networks. The authors note that several organizations following such a model (e.g., the Solutions for Patient Safety Network) have been successful in improving patient outcomes. While the networks described focus on pediatric care, they suggest that the same principles and processes could be applied to improve outcomes for other populations. A past PSNet perspective discussed the use of complex health care data to improve patient care.
Edwards MT. Am J Med Qual. 2016;32:148-155.
Organizations are encouraged to learn from their failures, but evidence shows that changes after errors are not always implemented. This commentary presents a model to help organizations learn from system failures through focusing on improvements that align collaboration, accountability, culture, and process enhancement with elements of high reliability.
Schilling L, Dearing JW, Staley P, et al. Jt Comm J Qual Patient Saf. 2011;37:532-43.
This article discusses Kaiser Permanente's efforts to develop a performance improvement system and become a learning organization.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
This paper investigates techniques for engaging frontline employees in proactive organizational improvement instead of creating individual workarounds.
Donaldson L. London, UK: The Stationery Office, 2000.
An Organisation with a Memory set out to understand what was known about the scale and nature of serious failures in the United Kingdom’s National Health Service (NHS) system, examine how the NHS might learn from those failures, and recommend methods to minimize future failures. The analysis was informed by not only medical evidence but also the expertise and experience of other high-risk industries such as aviation. The findings and analysis have been used to modernize the United Kingdom’s process for understanding error by addressing a key set of goals to create unified reporting mechanisms, support an open learning culture, ensure that lessons learned are applied and changes made, and to more broadly embrace the systems approach to minimize error.
Commentary
Classic
Edmondson A. Harv Bus Rev. 2011;89:48-55, 137.
Failures are inevitable in any industry, especially in one as complex as health care. The ability to learn from failures is a crucial characteristic of high reliability organizations, and creating a climate that emphasizes organizational learning is an essential element of safety culture. This article draws a distinction between preventable failures in predictable operations—which are largely due to slips, and can be prevented by interventions such as checklists—and unavoidable failures in complex organizations, which should be reported, analyzed, and treated as learning opportunities. The author, who has extensively analyzed high-profile failures in many industries, recommends that organizations maintain a learning culture, actively promote detection and reporting of problems by frontline staff, and promote experimentation and creative problem-solving in order to minimize the stigma of failures and enhance organizational learning from unexpected events.
