Implementation of a Patient Safety Collaborative Forum Facilitates Organizational Learning from Medical Error

Abstract

Societal awareness of medical errors has rapidly increased following the 1999 publication of the IOM report, To Err is Human (e.g., Kohn, Corrigan & Donaldson, 1999). This report encouraged hospitals to focus on patient safety as a central focus of quality improvement work and to develop proactive approaches to protect patients from medical error. Large hospitals often lack robust mechanisms for reliably identifying patient safety threats, developing effective countermeasures and broadly implementing those measures across the entire healthcare organization. The result is that patient safety activity is heterogeneous across a healthcare organization. Best practices regarding patient safety do not automatically spread horizontally in a hospital, but rather tend to remain isolated. Dartmouth-Hitchcock Medical Center (DHMC) is a large tertiary care facility and academic teaching hospital that self-identified this variation in patient safety processes as an organizational threat to patient safety. Internal reviews identified multiple examples of safety threats countered in one clinical unit, only to have an accident due to the same threat in a clinical unit physically proximate to the first. An Active Error Management (AEM) process utilized in the Department of Anesthesiology that was effective in supporting local learning was identified as a potential vehicle for organizational learning and horizontal spread of patient safety countermeasures. In this report we describe: a) the organizational intervention that was implemented - the Patient Safety Collaborative Forum (PSCF); b) the active error management process that was taught, modeled and coached via this vehicle for organizational learning; c) one example of organizational spread resulting from the PSCF; and finally d) a naturalistic experiment that compares best practice implementation among units that participated in the PSCF to those units that did not.