Towards the Development of a Resilience Engineering Tool to Improve Patient Safety

Abstract

Over the last few years, patient safety research has seen a paradigm-shift marked by the advent of Resilience Engineering (RE). Findings from the team’s previous research on the efficacy of root-cause analysis in improving patient safety revealed the potential to analyze existing resilient system properties and leverage the same in system-design and improvement. A multi-phase research plan to develop a lessons-learned system for resilience engineering in healthcare is described. The focus of this paper is the first phase, which involved critical-incident interviews to elicit detailed information from frontline health care workers regarding real-life examples of resilience. 14 interviews were conducted with clinicians and nurses from a large, multi-hospital medical system. Multiple examples of resilience and factors pertinent to patient safety were extracted and aligned with system capabilities which are the cornerstones of resilience – learning, responding, anticipating and monitoring. Resilience was also seen to manifest at various levels of the work organization. These results demonstrate the feasibility of using the critical incident interviewing method to analyze resilience in a healthcare organization. The data from the interviews will further be used to develop a Resilience Engineering Tool to Improve Patient Safety (RETIPS) that can be implemented organization-wide for reporting and analysis of resilience-based cases.