BLIP-ZIP SHELDR ADVICE: Systems Thinking and Triple Loop Learning in Patient Safety
If I had to sum up the infographic, it would be PRIDE. Pride in acknowledging making a mistake and solving a problem. Pride is taking responsibility for making a mistake and solving a problem. Feeling good in its resolution.
That’s the problem. We take pride in making mistakes or solving problems and move on.
How do we prevent mistakes, especially if could causes harm or falling short of expectations.
Systems thinking particularly in patient safety, involves understanding how interconnected components within a healthcare system influence patient outcomes. It's about recognizing that a patient safety issue isn't isolated but a result of complex interactions between people, processes, and technology.
For example, a medication error might not solely be due to a nurse's mistake, but could be influenced by factors like inadequate staffing, poor drug labeling, or a complex medication administration process.
Part of the systems thinking principles is Triple loop learning—framework for learning and improvement that goes beyond simply correcting errors, making mistakes, and solving problems. It involves taking pride in three levels of learning:
Single-loop learning: This is the most basic level, focusing on correcting the error itself. For example, if a patient receives the wrong medication, single-loop learning would involve ensuring the correct medication is administered next time.
Double-loop learning: This level involves questioning the underlying causes of the error. Why did the wrong medication get administered? Was it a labeling issue, a staffing shortage, or a poorly designed process? Addressing these root causes prevents similar errors from recurring.
Triple-loop learning: This is the deepest level of learning. It involves culture— questioning the underlying assumptions, values, and beliefs that led to the error. Does the healthcare system prioritize efficiency over safety? Are there cultural issues that prevent staff from reporting errors? Addressing these fundamental issues leads to systemic change and a culture of safety.
By adopting a systems thinking approach and engaging in triple loop learning, healthcare organizations can significantly improve patient safety. It's about creating a culture where errors are seen as opportunities for learning and improvement rather than blame.
Next time you take pride in making a mistake, think triple loop learning.
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Executive - Training & Development ||SincX|| MBA (HR, Marketing) ||
3moHealthcare is undoubtedly one of the most vital job roles, and we've witnessed several instances where the industry had to evolve, particularly during the COVID-19 era. Continuous improvement is the only way to deliver efficient results, and given that healthcare professionals have some of the busiest job roles, time is indeed an issue. E-learning helps by providing them with the flexibility to learn and gain knowledge at their preferred time