From blaming to learning:re-framing organisational learning from adverse incidents

摘要

This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting and learning approach from adverse incidents, could contribute towards individual and organisational approaches to patient safety. The study formed part of a series of six iterative action research cycles involving the collaboration of students (all National Health Service (NHS) staff) in the co-creation of knowledge and materials relating to understanding and learning from adverse incidents. This fifth qualitative study involved (n = 20) anaesthetists who participated in a two phase teaching intervention (n = 20 first phase, n = 10 second phase) which was premised on transformative learning, value placed on learning from adverse incidents and refraining the learning experience. An evaluation of the teaching intervention demonstrated that how students learned from adverse incidents, in addition to being provided with opportunities to transform negative experiences through re-framing learning, was significant in breaking out of practices which had become routine; prepositional knowledge on learning from adverse incidents, along with the provision of a safe learning environment in which to challenge assumptions about learning from adverse incidents, were significant factors in the re-framing process. The testing of a simulated dual learning/reporting system was indicated as a useful mechanism with which to reinforce a positive learning culture, to report and learn from adverse incidents and to introduce new approaches which might otherwise have been lost. The use of a "re-framed learning approach" and identification of additional leverage points (values placed on learning and effects of dual reporting and learning) will be of significant worth to those working in the field of individual and organisational learning generally, and of value specifically to those whose concern is the need to learn from adverse incidents. This paper contributes to individual and organisational learning by looking at a specific part of the learning system associated specifically with adverse incidents.