Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions

Health Care Manage Rev. Oct-Dec 2007;32(4):330-40. doi: 10.1097/01.HMR.0000296790.39128.20.

Abstract

Background: Preventable adverse events represent learning opportunities. Indeed, understanding and learning from preventable adverse events are the new organizational imperatives in health care. However, health services researchers note that there is a dearth of research on learning from failure in health care and, in industry, a limited capacity to learn from incidents and failure.

Purpose: We address the gap between awareness of preventable adverse events and knowledge that relates to how to respond to them effectively. We develop a multilevel model of learning and theorize factors that influence learning from preventable adverse events.

Methodology: Drawing upon theories of organizational learning and organizational behavior, we develop a multilevel model of learning from failure, where perceived characteristics of the events, group composition and dynamics, and the behavioral and structural arrangements of health care organizations are proposed to play important roles.

Practical implications: Our model highlights factors that facilitate learning from failure and others that impede it. Awareness and attention to these factors can help health care managers extract learning from failures, like preventable adverse events, and may ultimately contribute to reducing the occurrence of preventable adverse events and improving quality of care.

MeSH terms

  • Clinical Competence*
  • Decision Making, Organizational
  • Health Personnel / education*
  • Humans
  • Iatrogenic Disease / prevention & control*
  • Leadership
  • Learning*
  • Medical Errors / prevention & control*
  • Models, Educational*
  • Organizational Culture
  • Organizational Innovation
  • Quality Assurance, Health Care / methods
  • Quality Assurance, Health Care / organization & administration*
  • Safety Management
  • Staff Development / organization & administration*