Address correspondence to Peter E. Rivard, M.H.S.A., Research Associate, Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, 200 Springs Road (152), Bedford, MA 01730. Amy K. Rosen, Ph.D., Senior Research Scientist, is with the Center for Health Quality, Outcomes and Economic Research, Bedford, MA. John S. Carroll, Ph.D., is with the MIT Sloan School of Management, Cambridge, MA.
Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?
Article first published online: 9 JUN 2006
Health Services Research
Volume 41, Issue 4p2, pages 1633–1653, August 2006
How to Cite
Rivard, P. E., Rosen, A. K. and Carroll, J. S. (2006), Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?. Health Services Research, 41: 1633–1653. doi: 10.1111/j.1475-6773.2006.00569.x
- Issue published online: 9 JUN 2006
- Article first published online: 9 JUN 2006
- Patient safety;
- patient safety indicators;
- high-reliability organizations;
- organizational learning;
- administrative data
Objective. To assess the potential contribution of the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) to organizational learning for patient safety improvement.
Principal Findings. Patient safety improvement requires organizational learning at the system level, which entails changes in organizational routines that cut across divisions, professions, and levels of hierarchy. This learning depends on data that are varied along a number of dimensions, including structure-process-outcome and from granular to high-level; and it depends on integration of those varied data. PSIs are inexpensive, easy to use, less subject to bias than some other sources of patient safety data, and they provide reliable estimates of rates of preventable adverse events.
Conclusions. From an organizational learning perspective, PSIs have both limitations and potential contributions as sources of patient safety data. While they are not detailed or timely enough when used alone, their simplicity and reliability make them valuable as a higher-level safety performance measure. They offer one means for coordination and integration of patient safety data and activity within and across organizations.