Stories from the Sharp End: Case Studies in Safety Improvement

Abstract

Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.

Finding order in heterogeneity: types of quality-improvement intervention publications

“…Articles on stories provided a chronological description of what happened as part of implementing a QII, but were not based on systematic data collection. Learning theory and practical application demonstrate the power of stories in communicating about quality improvement 93 – 95. We did not attempt to subdivide Category II articles; further discussion of these articles, however, might have been fruitful.…”

Establishing a Provincial Patient Safety and Learning System: Pilot Project Results and Lessons Learned

“…The goal of our pilot study was to identify strategies and conditions that would promote the adoption of PSLS and encourage reporting and learning behaviours in personnel. We aimed to foster a culture that would inspire individuals to report safety events and near misses and to use data to learn and improve (McCarthy and Blumenthal 2006). Our target audiences were front-line workers who report events, managers who follow up on reports, leaders who investigate serious incidents and executives who receive summarized data.…”

Development of a patient safety culture measurement tool for ambulatory health care settings: analysis of content validity

“…Among the acknowledged causes of medical errors are organizational cultures that do not support patient safety [3][4][5]. Researchers now caution that improvement in patient safety requires dramatic shifts in traditional organizational cultures within health care institutions as well as changes in patient care processes [6].…”