AbstractsMedical & Health Science

THE EXPERIENCE OF ERROR ON THE FRONT LINE OF CARE IN THE CONTEXT OF A HOSPITAL ORGANIZATIONAL CULTURE CHANGE INITIATIVE

by Samuel David Katzman




Institution: San Diego State University
Department:
Year: 2015
Record ID: 2062201
Full text PDF: http://hdl.handle.net/10211.3/137676


Abstract

In the United States today, experts estimate that more than fifty thousand people are killed by medical error annually; many others are injured. One of the ways hospital organizations have attempted to reduce medical error and increase patient safety is the adoption and promotion of a culture of safety, in which staff feel comfortable disclosing errors and empowered to take action to prevent them. My research explores how organizational patient safety efforts related to the culture of safety affect the care delivery practices of frontline healthcare personnel. This research evaluates the implementation of a local hospital's Just Culture initiative (designed to help the hospital improve patient safety by encouraging staff to feel more comfortable reporting events). It also analyzes findings in regard to organizational culture change efforts aimed at mitigating the effects of error in healthcare more broadly. It examines and then augments existing Hospital administrative survey data with data from ethnographic observations and interviews with frontline hospital staff in two different departments in order to gain insight into how healthcare providers perceive error as well as organizational efforts to address it. In doing so, it provides a richer understanding of the realities behind the statistics and rates upon which established patient safety culture analysis currently relies. Such an understanding may enable an increase in error reporting and make organizational culture change efforts more successful. Keywords: Patient safety, culture of safety, organizational culture, evaluation