Cultures for improving patient safety through learning: the role of teamwork.

Improvements in patient safety result primarily from organisational and individual learning. This paper discusses the learning that can take place within organisations and the cultural change necessary to encourage it. It focuses on teams and team leaders as potentially powerful forces for bringing about the management of patient safety and better quality of care.

[1]  I. M. Lyth.  Containing Anxiety in Institutions , 1992 .

[2]  M. Reith.  Risk Assessment and Management: Lessons from Mental Health Inquiry Reports , 1998, Medicine, science, and the law.

[3]  R. Hogan,et al.  What we know about leadership: Effectiveness and personality. , 1994 .

[4]  N. K. Uberoi.  Competing Through Knowledge , 1998 .

[5]  K. Roberts,et al.  From bhopal to banking: Organizational design can mitigate risk , 1993 .

[6]  J. Firth‐Cozens.  Healthy promotion: changing behaviour towards evidence-based health care. , 1997, Quality in health care : QHC.

[7]  J. Firth‐Cozens,et al.  Multidisciplinary teamwork: the good, bad, and everything in between , 2001, Quality in health care : QHC.

[8]  J. Firth‐Cozens.  Emotional distress in junior house officers. , 1987, British medical journal.

[9]  I. Janis.  Groupthink: Psychological Studies of Policy Decisions and Fiascoes , 1982 .

[10]  E. M. Katzman,et al.  Nurse-Physician Conflicts as Barriers to the Enactment of Nursing Roles , 1988, Western journal of nursing research.

[11]  K. Roberts.  Managing High Reliability Organizations , 1990 .

[12]  H. McKenna.  Nursing: quality in numbers. , 1998, Quality in health care : QHC.

[13]  J. Firth‐Cozens.  Tackling risk by changing behaviour. , 1995, Quality in health care : QHC.

[14]  R. Payne,et al.  Stress in health professionals , 1987 .

[15]  A. Edmondson.  Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error , 1996 .

[16]  Robert Hogan,et al.  The dark side of charisma. , 1990 .

[17]  J. Firth‐Cozens,et al.  Interventions to improve physicians' well-being and patient care. , 2001, Social science & medicine.

[18]  Michael A. West,et al.  Teamwork in primary health care. 1. Perspectives from organisational psychology , 1995 .

[19]  J. Firth‐Cozens,et al.  Occupational stress, clinical treatment and changes in job perceptions , 1992 .

[20]  J. Lindesay,et al.  An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people. , 1993, BMJ.

[21]  B. Brittain,et al.  Structuring the Design and Implementation of Leadership and Teamwork for Program Management , 1997, Healthcare management forum.

[22]  David C. Nagel,et al.  Human factors in aviation , 1988 .

[23]  N. Nicholson.  How hardwired is human behavior? , 1998, Harvard Business Review.

[24]  Donald N. Michael,et al.  Learning to Plan-And Planning to Learn , 1997 .

[25]  L. Murphy.  Organizational interventions to reduce stress in health care professionals , 1999 .

[26]  J Greenhalgh,et al.  Doctors' perceptions of the links between stress and lowered clinical care. , 1997, Social science & medicine.

[27]  Brian D. Steffy,et al.  Stress and medical malpractice: organizational risk assessment and intervention. , 1988, The Journal of applied psychology.

[28]  Tenbroeck Smith,et al.  Revisiting the Experience–Behavior Hypothesis: The Effects of Hurricane Hugo on Hazard Preparedness and Other Self-Protective Acts , 1999 .

[29]  Michael A. West,et al.  Handbook of Work Group Psychology , 1996 .

[30]  T. Mizrahi,et al.  Managing medical mistakes: ideology, insularity and accountability among internists-in-training. , 1984, Social science & medicine.

[31]  M. West.  Reflexivity and work group effectiveness:a conceptual integration , 1996 .

[32]  K R Jones,et al.  Organizational culture assessment before and after implementing patient-focused care. , 1997, Nursing economic$.

[33]  P. Senge.  The fifth discipline : the art and practice of the learning organization/ Peter M. Senge , 1991 .

[34]  A. Davies.  Patient defined outcomes , 1994, Quality in health care : QHC.

[35]  J. Firth‐Cozens,et al.  Hours, sleep, teamwork, and stress , 1998, BMJ.

[36]  Sidney J. Blatt,et al.  Interpersonal relatedness and self-definition: Two prototypes for depression , 1992 .

[37]  David G. Mathiasen.  Groups that work (and those that Don't): Creating Conditions for Effective Teamwork, edited by J. Richard Hackman. San Francisco, CA: Jossey-Bass 1990, 512 pp. Price: $39.95 cloth , 1991 .

[38]  Arthur S Blaiwes,et al.  Measurement of Team Behaviors in a Navy Environment , 1986 .

[39]  D. Garvin.  Building a learning organization. , 1993, Harvard business review.

[40]  Charles Vincent,et al.  Clinical risk management , 1995 .

[41]  K W Kizer,et al.  Promoting patient safety by preventing medical error. , 1998, JAMA.

[42]  R. Janoff-Bulman.  Shattered Assumptions: Towards a New Psychology of Trauma , 1992 .

[43]  Kenneth E. Clark,et al.  Measures of leadership , 1990 .

[44]  Larry Hirschhorn.  The Workplace Within: Psychodynamics of Organizational Life , 1988 .

[45]  P. Snowden.  Practical aspects of clinical risk assessment and management , 1997, British Journal of Psychiatry.

[46]  K. J. Sharma.  On learning to plan—And planning to learn: Donald N. Michael, Jossey-Bass Publishers, San Francisco, 1973, 341 pp., $12.50 , 1975 .

[47]  L. Aiken,et al.  Effects of specialization and client differentiation on the status of nurses: the case of AIDS. , 1997, Journal of health and social behavior.

[48]  C. Helms,et al.  Systems errors versus physicians' errors: finding the balance in medical education. , 1999, Academic medicine : journal of the Association of American Medical Colleges.

[49]  Leadership and the quality of care , 2001 .

[50]  Robert W. Keidel.  Rethinking organizational design , 1994 .

[51]  Robert L. Helmreich,et al.  Group interaction and flight crew performance , 1988 .

[52]  D M Berwick.  You cannot expect people to be heroes. , 1998, BMJ.

[53]  Dean Tjosvold,et al.  Team Organization: An Enduring Competitive Advantage , 1991 .

[54]  R L Helmreich,et al.  Pilot personality and crew coordination: implications for training and selection. , 1991, The International journal of aviation psychology.

[55]  P. Cambridge.  The First Hit: A case study of the physical abuse of people with learning disabilities and challenging behaviours in a residential service , 1999 .

[56]  A. Maynard,et al.  Rewarding healthcare teams , 1998, BMJ.

[57]  Diane M. Houston,et al.  Psychological distress and error making among junior house officers , 1997 .

[58]  D. Norman.  Categorization of action slips. , 1981 .

[59]  P. Birleson.  Learning Organisations: A Suitable Model for Improving Mental Health Services? , 1998, The Australian and New Zealand journal of psychiatry.

[60]  T. Wall,et al.  Minor psychiatric disorder in NHS trust staff: Occupational and gender differences , 1997, British Journal of Psychiatry.

[61]  D. Silverberg,et al.  Group discussions with the health care team--a method of improving care of hypertension in general practice. , 1990, Journal of human hypertension.

[62]  Daniel R. Ilgen,et al.  TEAMS EMBEDDED IN ORGANIZATIONS : SOME IMPLICATIONS , 1999 .

[63]  Larry Hirschhorn,et al.  The Psychodynamics of organizations , 1993 .