Abstract

Although it is assumed that information about “medical error” will be used for improvement and organizational learning, we know little about how this actually happens in patient care settings. This study examines how organizational and professional beliefs and practices influence how health care providers and managers make sense of potential and actual adverse events, and how this affects the flow and use of information for making improvements.

The research is based on an ethnographic case study of a medical unit in a large tertiary care hospital in Canada. Over seven months, I conducted 39 semi-structured interviews of 26 staff members, as well as observation of meetings and activities on the unit, and document review. Critical incident technique was used to elicit stories of successful and unsuccessful changes, and incidents that had been (and had not been) handled well. The analytic and interpretive work was guided by reflexive methodology and is based on grounded theory and discourse analysis.

The main findings and contributions of the study are: (1) Information needs of individuals (or groups) can be latent and may need to be revealed to them. (2) Identification of information needs and information seeking may be carried out by a surrogate. (3) Routines can break down as a matter of course, but adverse outcomes can be prevented when a surrogate intervenes to repair the routine. (4) Workers may not be as competent in critical thinking and information skills as might be assumed and required for their positions. (5) Checkland and Holwell's (1998) processes of organizational meaning (POM) model was adapted and extended by synthesis with Taylor's (1991) information use environment and the addition of information seeking. Front line staff are task-driven, coping with heavy workloads. This limits attention to and recognition of potential information needs and knowledge gaps. However, a surrogate in an information-related role may intervene successfully with staff and engage in preventive maintenance and repair of routines. I have mapped four key functions of that behaviour: boundary spanner, information broker, knowledge translator, and change champion. All four functions are important for facilitating changes to practice, routines, and the work environment to improve patient safety.