Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction?
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.


RESULTS
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.
Rivard
Peter E
PE
Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, 200 Springs Road (152), Bedford, MA 01730, USA.
Rosen
Amy K
AK
Carroll
John S
JS
D006268:Health Facilities; D006801:Humans; D007858:Learning; D019300:Medical Errors / Q000517:prevention & control*; D015279:Organizational Culture; D019984:Quality Indicators, Health Care; D017751:Safety Management / Q000458:organization & administration*; D014481:United States