A novel tool for organisational learning and its impact on safety culture in a hospital dispensary

Incident reporting as a key mechanism for organisational learning and the establishment of a stronger safety culture are pillars of the current patient safety movement. Studies have suggested that incident reporting in healthcare does not achieve its full potential due to serious barriers to reporting and that sometimes staff may feel alienated by the process. The aim of the work reported in this paper was to prototype a novel approach to organisational learning that allows an organisation to assess and to monitor the status of processes that often give rise to latent failure conditions in the work environment, and to assess whether and through which mechanisms participation in this approach affects local safety culture. The approach was prototyped in a hospital dispensary using Plan-Do-Study-Act (PDSA) cycles, and the effect on safety culture was described qualitatively through semi-structured interviews. The results suggest that the approach has had a positive effect on the safety culture within the dispensary, and that staff perceive the approach to be useful and usable.