Development of a measure of patient safety event learning responses

Health Serv Res. 2009 Dec;44(6):2123-47. doi: 10.1111/j.1475-6773.2009.01021.x. Epub 2009 Sep 2.


Objective: To define patient safety event (PSE) learning response and to provide preliminary validation of a measure of PSE learning response.

Data sources: Ten focus groups with front-line staff and managers, an expert panel, and cross-sectional survey data from patient safety officers in 54 general acute hospitals.

Study design: A mixed methods study to define a measure of learning responses to patient safety failures that is rooted in theory, expert knowledge, and organizational practice realities.

Extraction methods: Learning response items developed from the literature were modified and validated in front-line staff and manager focus groups and by an expert panel and second group of external experts. Actual learning responses gleaned from survey data were examined using exploratory factor analyses and reliability analysis.

Principal findings: Unique learning response items were identified for minor, moderate, major events, and major near misses by an expert panel. A two-factor model of major event learning response was identified (factor 1=event analysis, factor 2=dissemination/communication of learnings). Organizations engage in greater learning responses following major events than less severe events and, for major events, organizations engage in more factor 1 responses than factor 2 learning responses.

Conclusions: Eleven to 13 items can measure learning responses to PSEs of differing severity. The items are feasible, grounded in theory, and reflect expert opinion as well as practice setting realities. The items have the potential for use to assess current practice in organizations and set future improvement goals.

Publication types

  • Validation Study

MeSH terms

  • Cross-Sectional Studies
  • Emergency Service, Hospital
  • Focus Groups
  • Humans
  • Medical Errors / prevention & control
  • Personnel, Hospital
  • Problem-Based Learning*
  • Review Literature as Topic
  • Safety Management*
  • Surveys and Questionnaires / standards*