Patient safety incidents provide critical learning opportunities. However, many health care organizations struggle to turn these incidents into lasting improvements. Researchers from The Institute for Education Research at UHN examine the challenges of learning from patient safety incidents and identify factors that create barriers to effective learning.
Researchers conducted 15 in-depth interviews with staff members and physicians involved in patient safety incidents at a large academic health science centre. The interviews provided valuable insights into the investigation process and the broader factors that shape how information is shared and applied within the organization.
Key findings indicate that although incident investigation and follow-up procedures are thorough and well-defined, several factors hinder effective learning. Decisions on how to classify incidents are often influenced by differing professional perspectives and institutional priorities. This can cause non-physical incidents—like emotional distress, which can impact patients but are harder to track—to be overlooked during learning and improvement efforts. Additionally, privacy policies often remove key contextual details from reports to create a safe space for disclosure. However, this makes it more challenging to transfer learning across different cases.
To enhance organizational learning, health care organizations should have a more collaborative approach between patient safety teams and learning experts. By integrating their strengths, organizations can address not only the technical aspects of incident investigations but also the underlying social and political dynamics. Ultimately, this can transform incident reports into actionable insights to improve patient care.
Dr. Paula Rowland is the lead author of the study and a Scientist at The Institute for Education Research at UHN. At the University of Toronto, Dr. Rowland is a Wilson Centre Scientist in the Office of the Vice Dean Medical Education at the Temerty Faculty of Medicine, an Associate Professor (status only) in the Department of Occupational Science and Occupational Therapy and an Associate Professor at the Institute of Health Policy, Management, and Evaluation.
Melissa Lan is a co-author of the study and a Patient Safety and Quality Improvement Specialist at UHN as well as an Adjunct Lecturer at the Institute of Health Policy, Management, and Evaluation at the University of Toronto.
Cecilia Wan is a co-author of the study and a Patient Safety and Quality Improvement Specialist at UHN.
Laura Pozzobon is a co-author of the study and a Manager of Quality, Safety, and Clinical Adoption at UHN as well as an Adjunct Lecturer at the Lawrence S. Bloomberg School of Nursing at the University of Toronto.
This work was supported by UHN Foundation.
Rowland P, Lan MF, Wan C, Pozzobon L. Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations. J Health Organ Manag. 2025 Jan 14. doi: 10.1108/JHOM-08-2024-0334.