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Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians

Abstract : This study explores the workplace dynamics associated with physicians and medical mistakes. Two residency settings (i.e. surgery and intensive care) were subjected to direct observation for a period of 6 weeks, revealing a total of 46 mistakes and near-miss events. Key findings that suggest greater contextual barriers to the advancement of learning cultures in residency settings with respect to patient safety include the small number of mistakes and near misses that led to adverse patient outcomes, the high percentage of resident mistakes and near misses that occur in isolation, the prevalence of "easy to explain" mistakes and near misses, and the negative reactions of attending and resident physicians to instances of failure. Key findings that support greater opportunities for advancing learning cultures include the prevalence of commission errors over omission errors, leading to the potential for greater mistake visibility, as well as the prevalence of so-called "harmless" mistakes that provide a training opportunity for learning best practices. Taken together, the results suggest the need for a situational approach to determining how and when a learning culture founded on patient safety can be implemented and sustained. The study further demonstrates the value of qualitative methods such as the direct observation of physicians in patient safety research.