Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness

摘要

Learning from patient safety incidents is difficult; information is often incomplete, and it is not clear which incidents are preventable or which intervention strategies are optimal. Effective group processes are vital for learning but few studies in healthcare have examined in depth the processes involved and whether they are effective. The aims of this study were to identify factors that facilitated and hindered the process of analysing incidents in teams and to develop and apply a framework of indicators of effective analytic processes. Incident review meetings in acute care and mental health care were observed. Full field notes were analysed thematically. A framework of process measures was developed and used to rate each meeting using the field notes. Reliability was analysed. Factors hindering analysis were lack of organisational support, high workload and a managerial, autocratic leadership style. Facilitating factors were participatory interactions and strong safety leadership. Process measures showed deficits in critiquing the causes of incidents, seeking further information, critiquing potential solutions and solving problems that crossed organisational boundaries, supporting observational data on the importance of effective leadership. Organisational legitimacy, administrative support, training, tools for incident analysis, effective well trained leaders who empower the team and sufficient resources to manage the high workload were all identified in this study as necessary changes to improve learning. Future studies could develop and validate the proposed framework of process indicators to provide a tool for teams to use as an aid to improve the analysis of incidents.