Matches in SemOpenAlex for { <https://semopenalex.org/work/W2116713897> ?p ?o ?g. }
- W2116713897 endingPage "294" @default.
- W2116713897 startingPage "287" @default.
- W2116713897 abstract "<h3>Introduction</h3> The extent to which individuals in healthcare use near misses as learning opportunities remains poorly understood. Thus, an exploratory study was conducted to gain insight into the nature of, and contributing factors to, organisational learning from near misses in clinical practice. <h3>Methods</h3> A constructivist grounded theory approach was employed which included semi-structured interviews with 24 participants (16 clinicians and 8 administrators) from a large teaching hospital in Canada. <h3>Results</h3> This study revealed three scenarios for the responses to near misses, the most common involved ‘doing a quick fix’ where clinicians recognised and corrected an error with no further action. The second scenario consisted of reporting near misses but not hearing back from management, which some participants characterised as ‘going into a black hole’. The third scenario was ‘closing off the Swiss-cheese holes’, in which a reported near miss generated corrective action at an organisational level. Explanations for ‘doing a quick fix’ included the pervasiveness of near misses that cause no harm and fear associated with reporting the near miss. ‘Going into a black hole’ reflected managers9 focus on operational duties and events that harmed patients. ‘Closing off the Swiss-cheese holes’ occurred when managers perceived substantial potential for harm and preventability. Where learning was perceived to occur, leaders played a pivotal role in encouraging near-miss reporting. <h3>Conclusion</h3> To optimise learning, organisations will need to determine which near misses are appropriate to be responded to as ‘quick fixes’ and which ones require further action at the unit and corporate levels." @default.
- W2116713897 created "2016-06-24" @default.
- W2116713897 creator A5052029088 @default.
- W2116713897 creator A5065918252 @default.
- W2116713897 creator A5067690043 @default.
- W2116713897 creator A5077159626 @default.
- W2116713897 date "2012-02-22" @default.
- W2116713897 modified "2023-10-01" @default.
- W2116713897 title "Learning from near misses: from quick fixes to closing off the Swiss-cheese holes: Table 1" @default.
- W2116713897 cites W1538749266 @default.
- W2116713897 cites W1566671441 @default.
- W2116713897 cites W1584351643 @default.
- W2116713897 cites W1605824561 @default.
- W2116713897 cites W165586848 @default.
- W2116713897 cites W1780382453 @default.
- W2116713897 cites W1975344722 @default.
- W2116713897 cites W1981163329 @default.
- W2116713897 cites W1995214657 @default.
- W2116713897 cites W1996334495 @default.
- W2116713897 cites W2001306742 @default.
- W2116713897 cites W2004853130 @default.
- W2116713897 cites W2016190680 @default.
- W2116713897 cites W2047827025 @default.
- W2116713897 cites W2053169524 @default.
- W2116713897 cites W2077729777 @default.
- W2116713897 cites W2083449279 @default.
- W2116713897 cites W2092261095 @default.
- W2116713897 cites W2098201245 @default.
- W2116713897 cites W2108602026 @default.
- W2116713897 cites W2112098604 @default.
- W2116713897 cites W2120530657 @default.
- W2116713897 cites W2120728869 @default.
- W2116713897 cites W2130474596 @default.
- W2116713897 cites W2131227505 @default.
- W2116713897 cites W2142571375 @default.
- W2116713897 cites W2150029453 @default.
- W2116713897 cites W2155507435 @default.
- W2116713897 cites W2156435103 @default.
- W2116713897 cites W2164444769 @default.
- W2116713897 cites W2282526840 @default.
- W2116713897 cites W239122227 @default.
- W2116713897 cites W2400595654 @default.
- W2116713897 cites W2977605120 @default.
- W2116713897 cites W581903150 @default.
- W2116713897 cites W648876446 @default.
- W2116713897 doi "https://doi.org/10.1136/bmjqs-2011-000256" @default.
- W2116713897 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/22357777" @default.
- W2116713897 hasPublicationYear "2012" @default.
- W2116713897 type Work @default.
- W2116713897 sameAs 2116713897 @default.
- W2116713897 citedByCount "40" @default.
- W2116713897 countsByYear W21167138972013 @default.
- W2116713897 countsByYear W21167138972014 @default.
- W2116713897 countsByYear W21167138972015 @default.
- W2116713897 countsByYear W21167138972016 @default.
- W2116713897 countsByYear W21167138972017 @default.
- W2116713897 countsByYear W21167138972019 @default.
- W2116713897 countsByYear W21167138972020 @default.
- W2116713897 countsByYear W21167138972021 @default.
- W2116713897 countsByYear W21167138972022 @default.
- W2116713897 countsByYear W21167138972023 @default.
- W2116713897 crossrefType "journal-article" @default.
- W2116713897 hasAuthorship W2116713897A5052029088 @default.
- W2116713897 hasAuthorship W2116713897A5065918252 @default.
- W2116713897 hasAuthorship W2116713897A5067690043 @default.
- W2116713897 hasAuthorship W2116713897A5077159626 @default.
- W2116713897 hasConcept C10138342 @default.
- W2116713897 hasConcept C121332964 @default.
- W2116713897 hasConcept C127413603 @default.
- W2116713897 hasConcept C130963320 @default.
- W2116713897 hasConcept C144024400 @default.
- W2116713897 hasConcept C144133560 @default.
- W2116713897 hasConcept C15744967 @default.
- W2116713897 hasConcept C160735492 @default.
- W2116713897 hasConcept C162324750 @default.
- W2116713897 hasConcept C19165224 @default.
- W2116713897 hasConcept C206713868 @default.
- W2116713897 hasConcept C2777363581 @default.
- W2116713897 hasConcept C2778775528 @default.
- W2116713897 hasConcept C2779328685 @default.
- W2116713897 hasConcept C2780791683 @default.
- W2116713897 hasConcept C50522688 @default.
- W2116713897 hasConcept C62520636 @default.
- W2116713897 hasConcept C71924100 @default.
- W2116713897 hasConcept C77595967 @default.
- W2116713897 hasConcept C77805123 @default.
- W2116713897 hasConcept C85973986 @default.
- W2116713897 hasConceptScore W2116713897C10138342 @default.
- W2116713897 hasConceptScore W2116713897C121332964 @default.
- W2116713897 hasConceptScore W2116713897C127413603 @default.
- W2116713897 hasConceptScore W2116713897C130963320 @default.
- W2116713897 hasConceptScore W2116713897C144024400 @default.
- W2116713897 hasConceptScore W2116713897C144133560 @default.
- W2116713897 hasConceptScore W2116713897C15744967 @default.
- W2116713897 hasConceptScore W2116713897C160735492 @default.
- W2116713897 hasConceptScore W2116713897C162324750 @default.
- W2116713897 hasConceptScore W2116713897C19165224 @default.
- W2116713897 hasConceptScore W2116713897C206713868 @default.