در مقدمه چه رخ داده است: یادگیری سازمانی از یک آسیب جدی به بیمار

This exploratory case study examines how one hospital learned from an adverse event (AE), a medication overdose that seriously injured a patient. Using qualitative data analysis, we examined how four professional groups reacted to the AE: physicians, nurses, pharmacists, and representatives from the combined quality assurance and risk management departments. Following the AE, each professional group classified the event differently, assessed a different segment of history, made decisions about different issues, and chose different courses of action. Despite these differences, the physician, nursing and pharmacy management teams all decided on which solutions to implement before the first root cause analysis meeting was convened. Indeed, to understand how the hospital implemented changes in the aftermath of the AE, it was necessary to examine the learning from near misses and other warnings that preceded it. This case highlights the importance of the politics of organizational learning and raises theoretical and practical questions about how hospitals learn from potential and actual adverse events.

An influential Institute of Medicine (IOM) report (Kohn et al., 2000) raised public awareness of medical errors and their serious consequences for patients and the healthcare industry. Drug-related errors, in particular, continue to be common (Aspden et al., 2007), costly, and can be harmful to patients (Thomas et al., 1999 and Thomas et al., 2000). However, adverse drug events that lead to permanent injury or death are uncommon in a single hospital. The IOM report advised healthcare organizations to “implement mechanisms of feedback and learning from error” as one of the fundamental methods of improving patient safety (Kohn et al., 2000). Following the IOM report, two of the investigators initiated a research project to study how hospitals learn from medication errors. A hospital learns when decision makers weigh the organization’s experience as a basis for changing the routines that will guide future behavior (Levitt and March, 1988 and March, 1999). This definition emphasizes that organizational learning is a process rather than an outcome and, thus, need not result in change or improvement. Applying qualitative research methods, we interviewed healthcare providers and administrators at different levels of the hospital hierarchy who were familiar with the process of providing medications. The research project focused primarily on intensive care units (ICU) in three tertiary care teaching hospitals in the U.S. We selected Rashomon Hospital1 as a research site, in part, because it had developed programs for improving medication safety. The hospital pharmacy, for example, had invested considerable resources in carefully tracking and investigating medication-related incident reports. As part of this project, the investigators were conducting interviews in a Rashomon Hospital ICU, when a patient was seriously injured by a drug overdose. Coincidently, some of the study participants were directly involved in or familiar with the circumstances surrounding this preventable patient injury or “adverse event” (AE) and talked about it in their interviews. In the following case study, we delve into the details of the AE in order to identify the underlying processes (Yin, 1989) that influenced organizational learning from an adverse event.

This exploratory and serendipitous case study examines Rashomon Hospital’s efforts to learn from a medication-related adverse event. In this case, despite limited access to data, we found that four sets of healthcare professionals applied four different event classifications, and chose four different courses of action in response to the same adverse event. Notably, all of the healthcare provider management teams – representing physicians, nurses, and pharmacists – decided whether or not to implement changes in response to the AE, even before QA/RM representatives convened the first RCA meeting. Therefore, the AE provided an opportunity to implement change; indeed, the hospital learned following the AE, but not necessarily from it. But the urgent need to find solutions quickly in the aftermath of the AE and thus prevent recurring patient injuries did not foster a thorough search for alternative solutions. Rashomon Hospital’s experience raises theoretical and practical questions for future research. The interview data permitted investigators to observe some of the processes by which organizational learning in a hospital can fragment into independent streams of learning activities. The analysis of the events in the aftermath and prologue to the AE underscored the importance of examining the widely-recognized but often overlooked influence of the politics of organizational learning on decision outcomes. Furthermore, the case raised interesting parallels between the use of actual (and potential) adverse events as opportunities for implementing change in disparate organizational settings. Kingdon’s (1995) agenda-setting model might offer insights in constructing a conceptual framework for understanding how hospitals implement changes following an adverse event. In Rashomon Hospital, dedicated and highly-skilled healthcare professionals encountered obstacles as each group sought to learn how to ensure the safe dosing and dispensing of HH. Their conscientious and persistent efforts to improve patient safety raise practical questions about the trade-offs in how hospitals learn from their experience. This case highlighted some of the benefits and limitations of learning from near misses and warnings based on other hospitals’ experience. Such events offer critical opportunities both to identify problems (before they harm patients) and to explore alternative solutions. However, because of the uncertainties surrounding potential dangers, they may lack the capacity to trigger change. The case also suggests future research on how patterns of organizational learning are influenced by the reliance on professional expertise for learning and the use of professional norms as a means of controlling behavior. The gap between the National RCA model and its implementation in practice suggests that future research might focus on adapting the industry-based RCA model to hospital settings that are characterized not only by interprofessional task interdependence, but also by the interprofessional politics of organizational learning.