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Table 5 The integration of data and emergent themes

From: Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study

Theme

Category

Quantitative Data

Code

Individual-level learning

Intuiting

33% of respondents recognized near-misses correctly

Unfamiliarity with near-misses

The intention of reporting scored the lowest among the dimensions (4.13 ± 0.65)

Stronger intention of first-order problem-solving behaviour

Interpreting

50.7% of respondents indicated that they never or rarely reported near-misses to the Adverse Event Reporting System

There were only 22 records of near-misses in the Adverse Event Reporting System in 2020

Dominance of first-order problem-solving behaviour

Group-level learning

Interpreting

Group-level learning contributes the least to organizational performance (βGG = 0.284)

Unsystematic near-miss learning in the nursing unit

Integrating

Lack of evaluation and recording of near-miss learning in the nursing unit

Organizational-level learning

Integrating

The mean score of FB10 (When making decisions for the future, we do not seem to have any memory of the past) was lowest among all items of the Strategic Learning Assessment Map (‾x = 4.90)

Lack of integration of learning stocks among different nursing units

Institutionalizing

Lack of standardized near-miss management documentation

Nonexistence of the institutionalizing work of near-miss organizational learning

Feed-forward learning

Rare feed-forward learning

Large misalignment (βmisalignment=−0.339)

Suspension of near-miss organizational learning from the group level

Feed-back learning

Inconsistent comprehension of near-miss management

No need to report at the individual level

No need to report at the group level

Required to report at the organizational level

Poor utilization of near-misses in improving patient safety

No feed back towards near-miss learning