Building a Learning Management Framework for Patient Safety: Lessons From a Large Multistate System
Authors: Carmack April , Valleru Jahnavi , Baka DeeDee , Henderson Meghan , McCarter Sarah , Walsh Jeanene , Randall Kelly 
Published: September 2024

Background

Embracing a learning, transparent, and improvement culture is crucial for healthcare organizations to effectively learn from human errors and deliver safer, higher-quality patient care. However, the application of organizational learning in healthcare has been relatively narrow, necessitating the establishment of learning systems across healthcare organizations. This paper presents a novel learning management framework in a multistate health system, which is also a patient safety organization (PSO), facilitating a transition into a high reliability organization. We also provide initial results, uniquely contributing to the limited literature on healthcare learning management networks for patient safety.

Methods

We explore solutions for widespread learning from safety events in a large multistate U.S. healthcare system. We discuss the challenges of culture, technology, measurement systems, and barriers to learning from errors. We present our key driver diagram, critical details of implementing a learning network, and our initial findings, including the positive impact of the good catch program and the culture of safety survey. These initiatives have led to improved communication about errors and a growing willingness to learn from them, demonstrating the effectiveness of our learning management network. We also discuss the importance of data in organizational learning.

Results

From 2021 to 2023, the overall event reporting rate, which includes all severity levels of harm, increased by 22.41%, from 165.15 to 202.16 events per 10,000 patient days (p-value<0.0001). The reporting rate for near-miss events also rose by 20.50%, from 138.09 to 166.41 events per 10,000 patient days (p-value<0.0001). We attribute these improvements to enhanced data sharing and a culture of transparency the learning management network fosters. The “Communication about error” element in the culture of safety survey, with over 55,000 respondents, improved from 69.5% in 2020 to 70.6% in 2022 (p-value<0.0001), indicating better communication and a growing willingness to learn from errors. Feedback from over 1,000 PSO safe table participants highlighted a respectful and supportive atmosphere, acknowledging areas for improvement without blame.

Conclusion

In conclusion, we emphasize the comprehensive approach to patient safety, utilizing diverse strategies and evidence-backed methods to spread learning and data sources and reinforcing the commitment to “healing without harm.” Looking ahead, we aim to instill essential learning mindsets, create psychologically safe workplaces, and promote high reliability and safety behaviors. We remain optimistic that the maturation of the learning management network will ultimately contribute to a decrease in harm rates, aligning with our ongoing commitment to patient safety and continuous enhancement. Our future research will focus on further refining and expanding the learning management framework to significantly impact patient safety in healthcare organizations.