This paper explores the planning and implementation of corrective action in response to identified adverse events at a large high-performing teaching hospital. A mixed methodological approach that combined interviews with clinical and administrative actors and statistical analysis of 405 non-routine adverse events that occurred at the hospital over a 30-month period was employed to identify factors associated with corrective action prescription and completion. Analysis of qualitative and quantitative data indicated that corrective action planning and implementation in response to adverse events were shaped by institutional influences on the hospital’s quality management practices, predominantly state-level regulation that required corrective action for externally-reportable events and professional norms that discouraged organizational intervention in autonomous clinician practice. In logistic regression models, odds of planning a corrective action in response to an adverse event increased with regulatory reportability of the event, litigation risk of the event, number of departments involved in the event, and full or partial event causation by protocol violation or coordination error. Severity of injury to the patient was not identified as a predictor of corrective action planning. The odds of corrective action implementation were greater for action types involving remedial retraining or reinforcement of standards and those involving interventions in the task environment, while corrective actions involving interventions in professional roles and interactions were associated with a statistically-significant decreased odds of completion. Rates of completion were generally low across action categories, which interviews and medical case data analysis indicate may have been a product of diffuse responsibility for implementation among practicing clinicians untrained in process change, unrealistic action planning, and normative barriers to intervention in professional practice. Findings from this case study site shed light on the resilience of work process failure in health care delivery organizations and emphasize the importance of resource appropriation, goal-setting and change management support that meet the formidable challenges of effecting change in these and other complex, high-risk task settings.

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