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Article
Publication date: 14 January 2025

Paula Rowland, Melissa F. Lan, Cecilia Wan and Laura Pozzobon

Despite robust quality improvement efforts in healthcare, learning from patient safety incidents remains difficult. Our study explores counter-vailing powers shaping learning…

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Abstract

Purpose

Despite robust quality improvement efforts in healthcare, learning from patient safety incidents remains difficult. Our study explores counter-vailing powers shaping learning processes and possibilities in healthcare organizations, with a focus on social, political and organizational dynamics of learning.

Design/methodology/approach

Deploying concepts of situated curriculum, boundary work and interconnected knowledge practices, we interviewed staff and physicians (n = 15) in a large Academic Health Science Centre in Canada about their experiences of incident investigations and resultant information sharing. Our analytical strategy was abductive, drawing connections to sociology of the professions and learning sciences literature.

Findings

Incident investigation and follow-up processes are relatively robust for learning about incidents in the organization. However, learning from incidents remains difficult, complicated by the professional politics of incident classification, counter-vailing policies related to privacy, the organization of improvement work towards reporting, and an organizational focus on incidents with severe outcomes.

Practical implications

Participants advocated for a broader view of incidents, moving beyond classification and investigation based on severity of outcome to also include incidents that are “learning rich”. To that end, we argue for more research on the role of Patient Safety Specialists in organizational learning and more collaborations with learning sciences.

Originality/value

This paper illuminates ways in which robust information dissemination structures are an important but insufficient condition for learning from incidents. The argument goes beyond a prescriptive approach to learning from incidents to instead explore the competing visions and values implicated with improvement practices.

Details

Journal of Health Organization and Management, vol. ahead-of-print no. ahead-of-print
Type: Research Article
ISSN: 1477-7266

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Book part
Publication date: 1 February 2007

Dwight R. Merunka and Robert A. Peterson

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Review of Marketing Research
Type: Book
ISBN: 978-0-7656-1306-6

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Book part
Publication date: 1 January 2005

Lan Xia and Kent B. Monroe

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Review of Marketing Research
Type: Book
ISBN: 978-0-85724-723-0

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Book part
Publication date: 1 August 2017

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Qualitative Consumer Research
Type: Book
ISBN: 978-1-78714-491-0

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Book part
Publication date: 19 September 2019

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Marketing in a Digital World
Type: Book
ISBN: 978-1-78756-339-1

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Book part
Publication date: 2 September 2014

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Shopper Marketing and the Role of In-Store Marketing
Type: Book
ISBN: 978-1-78441-001-8

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Book part
Publication date: 13 June 2013

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Review of Marketing Research
Type: Book
ISBN: 978-1-78190-761-0

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Book part
Publication date: 3 July 2018

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Innovation and Strategy
Type: Book
ISBN: 978-1-78754-828-2

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Book part
Publication date: 27 June 2016

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Marketing in and for a Sustainable Society
Type: Book
ISBN: 978-1-78635-282-8

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Book part
Publication date: 2 May 2015

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Brand Meaning Management
Type: Book
ISBN: 978-1-78441-932-5

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