Learning from safety events in healthcare: A sensemaking and mental model perspective

Abstract

Organizational learning from safety relevant events is critical for improvement of healthcare practice. The identification of causes of safety events in hospitals and the design of improvements engage decision making processes that involve a high degree of interpretive activity by various professional groups (physicians, nurses, risk managers, pharmacists, etc.). From a sensemaking perspective (Weick, 1995, Weick, Sutcliffe, & Obstfeld, 2005), we conceptualize the event investigation and action planning processes as driven by cognitive structures that help individuals understand an event from their own perspective, based on their experience, anticipation of what could happen, professional education and situational perceptions. To better understand these processes, we propose an individual-level framework suggesting that the construction of causal scenarios and the design of improvements are influenced by habitual mental models that contain assumptions and knowledge about safety and accident causation as well as by the analysts’ perceived action repertoires in defining corrective actions. Various influences on the individual cognitive processes in event analysis are discussed, such as professional education, cognitive style, organizational tools, culture, and the use of safety theories. As the framework is intended to stimulate future research, potential research questions and methods are discussed