Sensemaking of patient safety risks and hazards.
In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. True sensemaking in patient safety must use both retrospective and prospective approach to learning. Sensemaking is as an essential part of the design process leading to risk informed design. Sensemaking serves as a conceptual framework to bring together well established approaches to assessment of risk and hazards: (1) at the single event level using root cause analysis (RCA), (2) at the processes level using failure modes effects analysis (FMEA) and (3) at the system level using probabilistic risk assessment (PRA). The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards. Without ownership engendered by such conversations, the possibility of effective action to eliminate or minimize them is greatly reduced.
Battles
James B
JB
United States Department of Health and Human Services, Agency for Healthcare Quality and Research, Center for Quality Improvement and Patient Safety, 540 Gaither Road, Rockville, MD 20850, USA.
Dixon
Nancy M
NM
Borotkanics
Robert J
RJ
Rabin-Fastmen
Barbara
B
Kaplan
Harold S
HS
D006268:Health Facilities; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D018570:Risk Assessment / Q000379:methods; D017751:Safety Management / Q000458:organization & administration*; D014481:United States