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By R. Ramanujam, D. Keyser, C. Sirio, D. Thompson, Ranga Ramanujam and Debra N. Thompson


1 A year-long case study examined how four hospitals, that increased their medication error reporting, used the data and to what effect. Findings suggest that the immediate challenge for reporting-driven patient safety initiatives may not be to increase reporting but rather to implement an organizational design that enables learning from data already being reported. Implications for healthcare organizations and policy include making the pursuit of patient safety strategically desirable; setting specific and challenging patient safety objectives; developing metrics that measure learning processes as well as outcomes; enhancing change management capabilities; and expanding patient safety roles for hospital staff.

Year: 2009
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