Context: Two unmatched blood units were transfused to a patient undergoing surgery. In order to learn from this kind of error, the department had to report the adverse event, the staff had to discuss the situation of what went wrong and why and how to improve their routines to prevent such errors in the future. In health care, learning to improve quality and safety needs to occur at the individual, team and organisational levels. However, most formal learning occurs at the individual level at the start of a professional career. Errors are too often seen as personal carelessness or incompetence to be corrected by "naming, blaming and shaming." However, errors occur within the context of teams in organisations and learning needs to move from the individual to the context. Thus, understanding and improving how health professionals work together in organisations is a crucial part of the efforts to improve patient care and safety.
Objective: The purpose of this paper is to show how health personnel can improve and avoid harmful errors in patient care by delivering care within the setting of a clinical team and addressing and analyzing errors through a systematic learning process. This paper describes this learning process in detail and shows how it can be applied to various clinical situations to improve patient safety.
Findings: Learning takes place on several levels: from single-loop learning (adaptive learning) through double-loop learning (reflection in and on action) to triple-loop learning (meta-learning), and extending ones understanding and competencies of how to learn individually and in groups. Linking professional knowledge (e.g. medical sciences) and improvement knowledge (knowledge of system improvement), and paying attention to multidisciplinary team learning, are crucial to understanding how patient care and safety can be improved in clinical microsystems.