Soon to Appear in the American Journal of Medical Quality

1/21/2016 - Dr. Marc Edwards of QA to QI Patient Safety Organization announced that his manuscript, "An Organizational Learning Framework for Patient Safety," has been accepted for publication in the American Journal of Medical Quality. The work fills a vacuum in the field of patient safety, which has struggled to deliver on its promise for highly reliable, harm-free care.

"I'm glad to have finally arrived," said Dr. Edwards. "This baby had an exceptionally long gestation. I started this project over four years ago in reaction to themes I heard at an AHRQ-sponsored meeting of Patient Safety Organizations. My initial effort was not well-received."

"I regrouped by putting it aside and focusing instead on crafting a piece about Removing Barriers to High Reliability and developing a High Reliability Storyboard to help leaders communicate the need for change. I was fortunate to have received thoughtful feedback from many healthcare leaders here and abroad. In the process, I saw the need to revise and refine the framework."

"Last fall, I got the bug to revisit the manuscript and was surprised at how relatively easy it was to to restructure it to create a more compelling message. The AJMQ has been a pleasure to work with. The initial peer review process went quickly and I received very encouraging and useful feedback that pushed me to strengthen and polish the work."

Reviewer Comments to the Author

You have done an excellent job in my view of improving the clarity and structural understandability of this important paper, and I have no further suggestions for improvement. I would also like to specifically commend you for the most eloquent and correct statement yet written in regard to the limited time we have before bad solutions are imposed on us by a confused congress responding to a public groundswell of outrage—your lead paragraph under Conclusions. Very well stated. I look forward to seeing this work in print and I thank you for the refreshing frankness of your well-buttressed observations.

Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. February 25, 2016 doi:10.1177/1062860616632295

Article Abstract

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This manuscript presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the under-developed modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

Marc T. Edwards

Marc T. Edwards, MD, MBA is President and CEO of QA to QI LLC. He operates a Patient Safety Organization, conducts research in healthcare operations improvement, markets clinical peer review program management software, and assists clients to make improvements in quality, safety and resource use. For additional information, visit or contact him directly:; 860.521.8484.

QA to QI Patient Safety Organization (West Hartford, CT; specializes in the development of evidence-based tools for healthcare improvement through operations research.