Organizational learning and feedback to staff

A key question related to system implementation is, "What is the organization's appetite for learning about safety issues and then responding to that information?"

In answering that question, one must determine whether or not the organization is prepared to learn from its errors. As MERS-TM is introduced, employees should be told specifically what types of error they are expected to report. Feedback to staff about the event reporting program shows that event reports are not simply going into a black hole. If the event reporting program becomes a data collection exercise and no consequent improvement efforts are made, users will not be motivated to continue reporting.

Staff need to be informed whether or not improvement efforts are being undertaken or what processes are being examined for possible change due to input from event reports. In addition, hospital management will be looking for evidence that the system is leading to safety improvements.

MERS-TM must not stop at reporting events, but contribute to organizational learning and result in improvements related to product and patient safety.