An Organisation Without a Memory: a Qualitative Study of Hospital Staff Perceptions on Reporting and Organisational Learning for Patient Safety

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Abstract

Following the Public Enquiry into avoidable deaths and poor standards of care at Mid Staffordshire NHS Foundation Trust, the English National Health Service (NHS) is aiming to become a system devoted to continual learning and improvement of patient care. The paper aims to explore current perceptions of healthcare staff towards reporting and organisational learning for improving patient safety. Based on a Thematic Analysis of semi-structured interviews with 35 healthcare professionals in two NHS organisations, the paper argues that previously identified barriers to incident reporting remain problematic, and that less centralised processes that aim to learn from everyday clinical work might be better suited to generate actionable learning and change in the local work environment. The findings might support healthcare organisations in understanding better the practical processes of organisational learning at the local level. The findings might also support researchers in developing new approaches and strategies for integrating learning about risk at the local level with effective organisational change to improve patient safety.