Classifying and interpreting threats to patient safety in hospitals: insights from aviation
✍ Scribed by Michal Tamuz; Eric J. Thomas
- Publisher
- John Wiley and Sons
- Year
- 2006
- Tongue
- English
- Weight
- 183 KB
- Volume
- 27
- Category
- Article
- ISSN
- 0894-3796
- DOI
- 10.1002/job.419
No coin nor oath required. For personal study only.
✦ Synopsis
Abstract
We examine how the information gathered about patient safety‐related events is influenced by the interpretation and classification of these events in hospitals and by the context in which hospitals operate. Building on aviation safety studies, we developed research questions to guide a qualitative, interview‐based study of three hospitals. We found that having a specific (or general) definition of an event was important for aviation safety information systems, but was not salient for hospitals. In these hospitals, event classification was influenced by professional perspectives, perceived professional responsibility, event contingencies, and surveillance technology. In both contexts, decision makers avoided reporting potentially dangerous events by classifying them in non‐reportable categories. The importance of industry context for these results underscores the need for industry‐specific midlevel conceptual frameworks. Healthcare policy‐makers advocate standardizing event definitions to promote learning, but if organizational factors influence definitions and classification schemes, this may undermine the usefulness of centralized error reporting. Copyright © 2006 John Wiley & Sons, Ltd.