Abstract
Although it is assumed that information about patient safety and adverse events will be used for improvement and organizational learning, we know little about how this actually happens in patient care settings. This study examines how organizational and professional practices and beliefs related to patient safety influence (1) how health care providers and managers make sense of patient safety risks and adverse events, and (2) the flow and use of information for making improvements. The research is based on an ethnographic case study of a medical unit in a large tertiary care hospital in Canada. The study found that frontβline staff are task driven, coping with heavy workloads that limit their attention to and recognition of potential information needs and knowledge gaps. However, a surrogate in an informationβrelated roleβan βinformation/change agentββmay intervene successfully with staff and engage in preventive maintenance and repair of routines. The article discusses four key functions of the information/change agent (i.e., boundary spanner, information seeker, knowledge translator, and change champion) in the context of situated practice and learning. All four functions are important for facilitating changes to practice, routines, and the work environment to improve patient safety.