Are We Learning Lessons In Healthcare Since The Publication Of An Organisation With A Memory Department Of Health 2000?

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Acknowledgement

For this research, I would like to thank my family, friends and specifically my supervisor, for supporting and guiding me throughout my journey of learning. Without their support, it would not have been possible for me to conduct this research.

Abstract

In this study we try to explore the lesson learned from organisation with a memory in a holistic context. The main focus of the research is on the growth in medical incident reporting and its relation with lesson learned from the mistakes in the healthcare industry. The study focuses on the UK healthcare sector. The research also analyses many aspects of medical incident reporting and tries to examine the factors affecting it. Finally the research describes suggestions to enhance the medical incident reporting. The study is conducted using secondary methodology. The inclusion criteria for the literature were studies related to the topic and scoping in UK and published after “an organisation with a memory.” The results show that since 2003 there has been an increase in incident reporting in UK healthcare sector. But this growth has decreased since the last 3 years. There are two reasons for this decrease in growth. First, organisations have learned from their mistakes, thereby showing that “organisation with a memory” has been successful. The second reason is that there are still some barriers that hinder incident reporting. If these barriers are reduced then incident reporting will improve, which will lead to increase in organisational learning.

Table of Contents

ACKNOWLEDGEMENTII

ABSTRACTIII

INTRODUCTION1

THE LITERATURE SEARCH AND THE DEVELOPMENT OF THE MATRICES4

Data collection procedure4

Research Approach5

Search terms - key terms6

Inclusion Exclusion Criteria6

MAIN DISCUSSION7

Organisational Memory7

Incident Reporting in Health Care8

Incident Reporting and Organisational Learning10

Challenges Faced12

Quality improvement and resistance to change13

Barriers to Reporting16

Under-reporting of Adverse Events21

Problems with Learning from Patient Safety Incidents22

Inhibitors to Collective Learning23

Inhibitors to Systems Thinking24

Role of Nurse in Incident Reporting25

Findings from NRLS27

RECOMMENDATIONS31

Suggestions for the Improvement of Medical Incident Reporting31

Leadership and Safety Culture34

Financial and Legal34

Technology and Rapid Change35

Lessons Learned From Other Industries36

SUMMARY AND CONCLUSIONS37

Conclusion37

Recommendation for Future Research39

REFERENCES41

APPENDIX44

Matrix Table44

Introduction

Medical incidents can be a serious problem in the health care system. Some errors can even become life threatening, as well as prolong a hospital stay for the patient. It is important to find ways to prevent medical incident. While this may not be an immediate goal, it can be something to strive for in the future. Determining causes of errors and how they are made is the key to learning how to prevent them. There are many aspects to consider regarding a medication medical incident, but the purpose of this study is to look at the proposal that the reporting of a medical incident may be increased if the reporters name is anonymous (Bird, 2005, 1). Nurses and health care professionals are often hesitant to report all errors made due to fear of disciplinary action, but it is believed that by making the reporting process anonymous that the process will increase, and by increased reports we can learn from ...