Every year, tens of thousands of patients in North America die from preventable errors. Incident learning can decrease this number, but is not currently reaching its full potential in health care. The goal of this research was to propose strategies to effectively report and learn from incidents to drive quality improvement. A detailed literature review, focus groups, in-depth interviews, and thematic analysis were used to identify potential process improvement strategies from aviation and nuclear power and assess these strategies for feasibility and desirability in health care. This work was guided by World Health Organization recommendations and Rasmussen’s risk management framework. An extensive list of strategies to address existing shortcomings was ultimately proposed for consideration in health care. These strategies can serve as guidelines to proactively improve incident learning processes. This should help create more effective systems and in turn, improve patient safety.
| Identifer | oai:union.ndltd.org:TORONTO/oai:tspace.library.utoronto.ca:1807/42878 |
| Date | 27 November 2013 |
| Creators | Hanbidge, Michelle |
| Contributors | Easty, Anthony, Trbovich, Patricia |
| Source Sets | University of Toronto |
| Language | en_ca |
| Detected Language | English |
| Type | Thesis |
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