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Please use this identifier to cite or link to this item: http://hdl.handle.net/1807/24772

Title: Organizational Learning From Near Misses in Health Care
Authors: Jeffs, Lianne Patricia
Advisor: Baker, G. Ross
Department: Health Policy, Management and Evaluation
Keywords: Near Misses
Organizational Learning
Patient Safety
Issue Date: 13-Aug-2010
Abstract: How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.
URI: http://hdl.handle.net/1807/24772
Appears in Collections:Doctoral
The Institute of Health Policy, Management and Evaluation - Doctoral theses

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