Evaluating Hospitals’ Responses to Patient Safety Events

Abstract

Adverse events—defined as unintended harm associated with the delivery of healthcare—can result in prolonged hospitalization, disability, or death of a patient. While most Canadians receive safe care, thousands of hospital-acquired adverse events still occur annually, nearly half of which might be preventable, imposing a significant economic burden. To mitigate this, patient safety learning systems (PSLSs) have been developed to promote learning from incidents and prevent recurrence. These systems offer critical insights into how and why harm occurs at the organizational level, but they face limitations to their implementation and evaluation. More than two decades have passed since the landmark report "To Err is Human" was published, but patient harm during hospitalization remains prevalent. This might be due to barriers to implementing a PSLS or to the biased evaluations that obscure the areas needing improvement. The overarching aim of this doctoral thesis was to address key evidence gaps relevant to strengthening a hospital’s response to safety events and lay a foundation for future evaluation studies. The first of three studies synthesized current evidence on the barriers and enablers to implementing the PSLS through a systematic review and meta-synthesis. The barriers identified included inadequate organizational support, resource shortages, lack of training, weak safety culture, lack of accountability, punitive environments, complex systems, and lack of feedback. Enablers included continuous training, leadership as role models, balanced accountability, anonymous reporting, user-friendly platforms, well-structured analysis teams, and evidence of improvement. The second study applied this evidence to develop a comprehensive, evidence-based self-assessment tool for PSLSs. Designed for use by hospitals, health systems, and researchers, the tool assesses the full spectrum of activities following safety events, helping organizations identify areas for improvement and enabling researchers to evaluate the effectiveness of a PSLS. The third study used this tool to evaluate PSLS capabilities in a sample of large, reputable general and university hospitals in Ontario. It identified critical areas of improvement for decision-makers and provided insight into practical PSLS challenges. Overall, this thesis has direct implications for improving PSLS-related policies and practices, and indirectly contributes to enhancing hospital safety culture by addressing barriers to implementation and integrating safety learning into daily routines.