A New Vision for Patient Safety Learning: Conceptualizing Unlearning in Routines and Practices

West MidlandsGeneric Health Relevance
Start Date: 1 Jan 2014

Project summary

This PhD will examine organizational learning and service development following root cause analysis (RCA) of serious patient safety incidents through identifying the barriers and enablers to learning. Healthcare is a rich empirical setting for carrying out research grounded in organisational studies, in particular theories related to professional power, knowledge management, and organisational learning. Unfortunately, it has been found that hospitals rarely learn from failure: several researchers have hypothesized this is the result of challenges and barriers including a prevailing culture of blame, an organisational environment that promotes quick fixes and work-arounds, and a normalization of deviance among staff, who view patient safety incidents as normal and routine. There have been numerous studies analysing the efforts of healthcare organizations to learn from patient safety incidents to prevent recurrence. These studies have generally focused on identification of risks, analysis of patient safety incidents using tools such as RCA, and sharing of lessons learned via publishing formal reports of recommendations for improvement. There has been little research that investigates how healthcare organizations are accountable for implementing, embedding, sustaining and monitoring these recommendations, and to ensure service improvements are made, which prevent reoccurrences and improve patient safety. This PhD will focus on analysing these critical steps of the patient safety learning process through a qualitative study of three RCA case studies at the Heart of England NHS Foundation Trust that will include interviews with staff, committee observation, and documentation reviews. A historical review of RCA practice in high reliability industries such as aviation, manufacturing, and nuclear power will be analyzed to understand how RCA has been successfully utilized to improve safety in these industries, and what lessons can be learned for healthcare. RCA success from these industries will be looked at critically to determine what role professional power and knowledge has played in safety improvement and learning initiatives, and how we can apply this to healthcare. Theoretical development will be iterative in nature and involve a back-and-forth between the existing literature, data collection, and data analysis.

John G. Richmond