Grant: Knowledge Translation Supplement - PA: Health Services and Policy Research

Despite a decade of intense effort, the problem of patient harm in health care facilities remains a challenge. A recent study of 10 hospitals in North Carolina, which have actively engaged in patient safety initiatives reported rates of adverse events (AEs) similar to those reported by the Institute of Medicine report "To Err is Human" in 1999. We believe the difficulty in making significant headway on the patient safety agenda is due in part to the fact that a) it was always going to be a long (indeed never ending) struggle -- aviation for example took almost 60 years to become ultra-safe -- and b) in part, to misunderstanding of the nature of the dynamics that are involved in the generation of adverse events in risk critical industries. Commissioned research undertaken by Baker et al (2010) emphasizes the need to develop the knowledge, skills and expertise of healthcare board members. The objective of the proposed project is to develop web-based tools that are designed to support health care board members and senior executives, specifically, to broaden their knowledge and skills related to understanding safety science and improving their capacity to govern their organizations with respect to safety and quality. We will develop web-based tools to configure the key findings from our Canadian Health Services Research Foundation REISS grant activities, to make them relevant to health care senior executive teams and board members. The work will engage input from 5 collaborators with knowledge, expertise and experience at the senior leadership level, and one of the collaborators is an expert in knowledge translation. Their input will guide the development of web-based materials designed to inform senior leaders and board members about safety science in general, and resilience in particular. Unlike other perspectives on safety that focus solely on adverse event prevention, resilience emphasizes successful operations under varying conditions and challenges