Harrison M, Tamuz M; AcademyHealth. Meeting (2005 : Boston, Mass.).
Abstr AcademyHealth Meet. 2005; 22: abstract no. 4246.
Agency for Healthcare Research & Quality, Center for Delivery, Organization, and Markets, 540 Gaither Rd., Rockville, MD 20850 Tel. 301-427-1434 Fax Fax: 301-427-1430
RESEARCH OBJECTIVE: To identify the distinctive contributions of two leading organizational approaches to safety in high-hazard industries. To specify conditions under which these theories apply to hospitals. STUDY DESIGN: A qualitative, interview-based study of learning from medication errors in hospitals provides examples for our review of empirical and theoretical studies of high reliability organizations (HRO) and normal accident theory (NAT) in hospitals and high-hazard industries. POPULATION STUDIED: Three tertiary care teaching hospitals (n=342 healthcare professionals and administrators) PRINCIPAL FINDINGS: (1)Developing Culture: HRO emphasizes that organizational culture influences safety. Researchers advocate developing a culture of mindfulness through noticing hazards. Unfortunately, planned cultural change is usually slow, hard to manage, and risky. Interviews with clinicians illustrate how turnover, employment arrangements, and professional education undermined development of mindful cultures. (2)Designing Organizational Structures and Technologies: NAT highlights how organizational structure and technology contribute to errors by intensifying interactive complexity and coupling. Hospitals are characterized by interactive complexity, but traditionally their clinical processes have been loosely coupled. Loose coupling leads to inefficiency, but provides opportunities to catch errors before they cause harm. Tradeoffs in loose coupling were evident in interviews with providers who order, dispense, and administer medications. When adverse events do occur to individual patients in loosely-coupled health systems, they do not usually spread. Recent technological developments, such as computerized order entry, tighten links among units and functions (e.g., ordering and dispensing medication). Although these information technologies improve efficiency and routine safety, they may also increase the chances of errors spreading across patients and units. (3)Specifying Conditions for HRO Solutions: HRO advocates continuous training, but training cannot solve problems from poorly designed systems. NAT suggests that other HRO solutions might actually reduce hospital safety. For instance, adding redundancies by increasing human or technological checks can make processes harder to understand and reduce clinicians vigilance. In interviews, pharmacy managers observed that redundancy could lead to complacency and medication errors.(4)Implementing Changes: NAT and HRO agree on some safety solutions, but differ on how to implement them. Both perspectives recognize the importance of rewarding safety-promoting activities. HRO assumes that safety cultures readily create appropriate reward systems. NAT sees developing reward systems as problematic. In practice, employees are subject to conflicting expectations and rewards. As NAT anticipates, in interviews nursing managers reported being subject to conflicting incentives for reducing errors and encouraging error reporting. CONCLUSIONS: NAT provides a more realistic image of hospital operations than HRO and reveals barriers to implementing HRO solutions. The cultural changes envisioned by HRO may slowly yield safety benefits; NAT highlights the immediate political impact of competing goals and conflicting reward systems. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: HRO advocates the long-term advantages of promoting a culture of mindfulness and immediate benefits of conducting safety audits. NAT underscores the potential contribution of safety monitoring and promotion by external stakeholders (e.g., JCAHO) to tip the internal balance towards patient safety. NAT cautions against adding redundancies and warns of possible risks of tightly coupling operations through information technology or efficiency measures.
Publication Types:
Keywords:
- Data Collection
- Hospitals
- Humans
- Interviews as Topic
- Joint Commission on Accreditation of Healthcare Organizations
- Medication Errors
- Organizational Culture
- Organizations
- Research Design
- Safety
- drug therapy
- therapy
- hsrmtgs
UI: 103623709
From Meeting Abstracts