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Patient Safety Learning Pilot: Narratives from the Frontlines.


In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors.


Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.
Advances in Patient Safety.

Author information

Centers for Medicare & Medicaid Services (Dr. Kellie, at the time of this study); Agency for Healthcare Research and Quality (Dr. Battles); Common Knowledge Associates (Dr. Dixon); Columbia University (Dr. Kaplan and Ms. Fastman). Note: Dr. Kellie is now with the American Medical Association


Although patient safety experts have focused on event reporting and on the role of sensemaking and human factors in learning from events, there has been little study of how these factors are received and used by frontline hospital workers. Consequently in 2003, the Centers for Medicare & Medicaid Services—in collaboration with patient safety experts and the Agency for Healthcare Research and Quality—designed and implemented a patient safety improvement prototype in four hospitals. The prototype included an event reporting system (the Medical Events Reporting System - Total HealthSystem [MERS-TH]); use of collective sensemaking to maximize learning from events; and a focus on the role of human factors engineering in understanding events and in finding remedies for the causes of system failures. Study findings showed that both the MERS-TH methods and tools and collective sensemaking were extremely useful to frontline hospital workers for increasing learning from events. In addition, although frontline workers came to understand the value of human factors engineering in reducing patient harm, they were faced with limited access to this expertise at the community hospital level.

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