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 |