Skip to main content

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review

Advances in Health Sciences Education volume 18, pages 787–805 (2013)Cite this article

Abstract

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References

  • Aboumatar, H. J., Blackledge, C. G., Dickson, C., Heitmiller, E., Freischlag, J., & Pronovost, P. J. (2007). A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: Results of the morbidity and mortality conference improvement study, Phase 1. American Journal of Medical Quality, 22(4), 232–238.

    Article  Google Scholar 

  • Aitken, R. J., Nixon, S. J., & Ruckley, C. V. (1997). Lothian surgical audit: A 15-year experience of improvement in surgical practice through regional computerised audit. The Lancet, 350(9080), 800–804.

    Article  Google Scholar 

  • Albolino, S., Tartaglia, R., Bellandi, T., Amicosante, A. M., Bianchini, E., & Biggeri, A. (2010). Patient safety and incident reporting: Survey of Italian healthcare workers. Quality and Safety in Health Care, 19(Suppl 3), i8–i12.

    Article  Google Scholar 

  • Baker, G. R. (2004). Harvard medical practice study. Quality and Safety in Health Care, 13(2), 151–152.

    Article  Google Scholar 

  • Battles, J. B., Dixon, N. M., Borotkanics, R. J., Rabin-Fastmen, B., & Kaplan, H. S. (2006). Sensemaking of Patient Safety Risks and Hazards. Health Services Research, 41(4p2), 1555–1575.

    Google Scholar 

  • Bauer, J., & Mulder, R. H. (2010). In search of a good method for measuring learning from errors at work. In M. Van Woerkom & R. Poell (Eds.), Workplace learning. Concepts, Measurement, and Application. New York, NY: Routledge.

  • Bechtold, M. L., Scott, S., Dellsperger, K. C., Hall, L. W., Nelson, K., & Cox, K. R. (2008). Educational quality improvement report: Outcomes from a revised morbidity and mortality format that emphasised patient safety. Postgraduate Medical Journal, 84(990), 211–216.

    Article  Google Scholar 

  • Benn, J., Koutantji, M., Wallace, L., Spurgeon, P., Rejman, M., Healey, A., et al. (2009). Feedback from incident reporting: Information and action to improve patient safety. Quality and Safety in Health Care, 18(1), 11–21.

    Article  Google Scholar 

  • Berenholtz, S. M., Hartsell, T. L., & Pronovost, P. J. (2009). Learning from defects to enhance morbidity and mortality conferences. American Journal of Medical Quality, 24(3), 192–195.

    Article  Google Scholar 

  • Bismark, M. M., Brennan, T. A., Paterson, R. J., Davis, P. B., & Studdert, D. M. (2006). Relationship between complaints and quality of care in New Zealand: A descriptive analysis of complainants and non-complainants following adverse events. Quality and Safety in Health Care, 15(1), 17–22.

    Article  Google Scholar 

  • Boakes, E. (2009). Using foresight in safe nursing care. Journal of Nursing Management, 17(2), 212–217.

    Article  Google Scholar 

  • Brennan, T. A., Leape, L. L., Laird, N. M., Hebert, L., Localio, A. R., Lawthers, A. G., et al. (1991). Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324(6), 370–376.

    Article  Google Scholar 

  • Cairns, L., & Malloch, M. (2010). Theories of work, place and learning: New directions. In M. Malloch, L. Cairns, K. Evans, & B. N. O’Connor (Eds.), The Sage handbook of workplace learning (pp. 3–16). London: Sage.

    Google Scholar 

  • CanMEDS. (2005). Royal College of Physicians and Surgeons of Canada: CanMEDS 2005 Framework. Available: http://www.royalcollege.ca/shared/documents/canmeds/the_7_canmeds_roles_e.pdf. Accessed 2 Jun 2012.

  • Collins, J. A., & Fauser, B. C. J. M. (2005). Balancing the strengths of systematic and narrative reviews. Human Reproduction Update, 11(2), 103–104.

    Article  Google Scholar 

  • Cooke, D. L., Dunscombe, P. B., & Lee, R. C. (2007). Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. Quality and Safety in Health Care, 16(5), 342–348.

    Article  Google Scholar 

  • Cross, J. (2007). Informal learning: Rediscovering the natural pathways that inspire innovation and performance. San Francisco, CA: Pfeiffer.

    Google Scholar 

  • Cross, R., Borgatti, S. P., & Parker, A. (2002). Making invisible workvisible: Using social network analysis to support strategic collaboration. California Management Review, 44(2), 25.

    Google Scholar 

  • de Feijter, J. M., de Grave, W. S., Muijtjens, A. M., Scherpbier, A. J. J. A., & Koopmans, R. P. (2012). A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PLoS ONE, 7(2), e31125.

    Article  Google Scholar 

  • de Feijter, J. M., de Grave, W. S., Hopmans, E. M., Koopmans, R. P., & Scherpbier, A. J. J. A. Reflective learning in a patient safety course for final year medical students. Medical Teacher (accepted).

  • Eraut, M. (2004). Informal learning in the workplace. Studies in Continuing Education, 26(2), 248–273.

    Article  Google Scholar 

  • Flin, R., Patey, R., Jackson, J., Mearns, K., & Dissanayaka, U. (2009). Year 1 medical undergraduates’ knowledge of and attitudes to medical error. Medical Education, 43(12), 1147–1155.

    Article  Google Scholar 

  • Fussell, J. J., Farrar, H. C., Blaszak, R. T., & Sisterhen, L. L. (2009). Incorporating the ACGME educational competencies into morbidity and mortality review conferences. Teaching and Learning in Medicine, 21(3), 233–239.

    Article  Google Scholar 

  • Ginsburg, L. R., Chuang, Y.-T., Blair Berta, W., Norton, P. G., Ng, P., Tregunno, D., et al. (2010). The relationship between organizational leadership for safety and learning from patient safety events. Health Services Research, 45(3), 607–632.

    Article  Google Scholar 

  • Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peer-reviewed journals: Secrets of the trade. Journal of Chiropractic Medicine, 5(3), 101–117.

    Article  Google Scholar 

  • Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patients’ care. The Lancet, 362(9391), 1225–1230.

    Article  Google Scholar 

  • Hildebrand, C., Trowbridge, E., Roach, M., Sullivan, A., Broman, A., & Vogelman, B. (2009). Resident self-assessment and self-reflection: University of Wisconsin-Madison’s five-year study. Journal of General Internal Medicine, 24(3), 361–365.

    Article  Google Scholar 

  • Hogan, H., Olsen, S., Scobie, S., Chapman, E., Sachs, R., McKee, M., et al. (2008). What can we learn about patient safety from information sources within an acute hospital: A step on the ladder of integrated risk management? Quality and Safety in Health Care, 17(3), 209–215.

    Article  Google Scholar 

  • Holden, R. J., & Karsh, B.-T. (2007). A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Human Factors: The Journal of the Human Factors and Ergonomics Society, 49(2), 257–276.

    Article  Google Scholar 

  • Hollnagel, E. (2008). Risk + barriers = safety? Safety Science, 46(2), 221–229.

    Article  Google Scholar 

  • Hsieh, S. Y. (2011). A system for using patient complaints as a trigger to improve quality. Quality Management in Healthcare, 20(4), 343–355. doi:10.1097/QMH.1090b1013e318222e318273b.

  • Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10–28.

    Article  Google Scholar 

  • Jansma, J., Zwart, D., Leistikow, I., Kalkman, C., Wagner, C., & Bijnen, A. (2010). Do specialty registrars change their attitudes, intentions and behaviour towards reporting incidents following a patient safety course? BMC Health Services Research, 10(1), 100.

    Article  Google Scholar 

  • Jeffe, D. B., Dunagan, W. C., Garbutt, J., Burroughs, T. E., Gallagher, T. H., Hill, P. R., et al. (2004). Using focus groups to understand physicians’ and nurses’ perspectives on error reporting in hospitals. Joint Commission Journal on Quality and Patient Safety, 30(9), 471–479.

    Google Scholar 

  • Kessels-Habraken, M., De Jonge, J., Van der Schaaf, T., & Rutte, C. (2010). Prospective risk analysis prior to retrospective incident reporting and analysis as a means to enhance incident reporting behaviour: A quasi-experimental field study. Social Science and Medicine, 70(9), 1309–1316.

    Article  Google Scholar 

  • Kim, M. J., Fleming, F. J., Peters, J. H., Salloum, R. M., Monson, J. R., & Eghbali, M. E. (2010). Improvement in educational effectiveness of morbidity and mortality conferences with structured presentation and analysis of complications. Journal of Surgical Education, 67(6), 400–405.

    Article  Google Scholar 

  • Kohn, K. T., Corrigan, J. M., & Donaldson, M. S. (1999). To err is human. Building a safer health system. Washington, DC: National Academy Press.

    Google Scholar 

  • Kravet, S. J., Howell, E., & Wright, S. M. (2006). Morbidity and mortality conference, grand rounds, and the ACGME’s core competencies. Journal of General Internal Medicine, 21(11), 1192–1194.

    Article  Google Scholar 

  • Kuehster, C. R., & Hall, C. D. (2010). Simulation: Learning from mistakes while building communication and teamwork. Journal of Nursing Staff Development, 26(3), 123–127.

    Article  Google Scholar 

  • Leistikow, I. P., Kalkman, C. J., & de Bruijn, H. (2011). Why patient safety is such a tough nut to crack. BMJ, 342, d3447.

    Article  Google Scholar 

  • Levtzion-Korach, O., Frankel, A., Alcalai, H., Keohane, C., Orav, J., Graydon-Baker, E., et al. (2010). Integrating incident data from five reporting systems to assess patient safety: Making sense of the elephant. Joint Commission Journal on Quality and Patient Safety, 36(9), 402–410.

    Google Scholar 

  • Lewis, C. E., Relan, A., Hines, O. J., Tillou, A., & Hiatt, J. R. (2011). Morbidity and mortality as a televideoconference: A randomized prospective evaluation of learning and perceptions. Journal of the American College of Surgeons, 212(3), 400–405.

    Article  Google Scholar 

  • Lynch, D. C., Swing, S. R., Horowitz, S. D., Holt, K., & Messer, J. V. (2004). Assessing practice-based learning and improvement. Teaching and Learning in Medicine, 16(1), 85–92.

    Article  Google Scholar 

  • Macrae, C. (2008). Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health, Risk & Society, 10(1), 53–67.

    Article  Google Scholar 

  • Mahajan, R. P. (2010). Critical incident reporting and learning. British Journal of Anaesthesia, 105(1), 69–75.

    Article  Google Scholar 

  • Marsick, V. J., & Volpe, M. (1999). The nature and need for informal learning. Advances in Developing Human Resources, 1(3), 1–9.

    Article  Google Scholar 

  • Marsick, V. J., Volpe, M., & Watkins, K. E. (1999). Theory and practice of informal learning in the knowledge era. Advances in Developing Human Resources, 1(3), 80–95.

    Article  Google Scholar 

  • Marsick, V. J., & Watkins, K. E. (1990). Informal and incidental learning in the workplace. London: Routledge.

    Google Scholar 

  • Marsick, V. J., & Watkins, K. E. (2001). Informal and incidental learning. New Directions for Adult and Continuing Education, 89, 25–34.

    Google Scholar 

  • Marx, D. A., & Slonim, A. D. (2003). Assessing patient safety risk before the injury occurs: An introduction to sociotechnical probabilistic risk modelling in health care. Quality and Safety in Health Care, 12(suppl 2), ii33–ii38.

    Google Scholar 

  • McLaughlin, S. A., Doezema, D., & Sklar, D. P. (2002). Human simulation in emergency medicine training: A model curriculum. Academic Emergency Medicine, 9(11), 1310–1318.

    Article  Google Scholar 

  • Michel, P., Quenon, J. L., de Sarasqueta, A. M., & Scemama, O. (2004). Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ, 328(7433), 199.

    Article  Google Scholar 

  • Montesi, G., & Lechi, A. (2009). Prevention of medication errors: Detection and audit. British Journal of Clinical Pharmacology, 67(6), 651–655.

    Article  Google Scholar 

  • Olsen, S., Neale, G., Schwab, K., Psaila, B., Patel, T., Chapman, E. J., et al. (2007). Hospital staff should use more than one method to detect adverse events and potential adverse events: Incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality & Safety in Health Care, 16(1), 40–44.

    Article  Google Scholar 

  • Orlander, J. D., Barber, T. W., & Fincke, B. G. (2002). The morbidity and mortality conference: The delicate nature of learning from error. Academic Medicine, 77(10), 1001–1006.

    Article  Google Scholar 

  • Patey, R., Flin, R., Cuthbertson, B. H., MacDonald, L., Mearns, K., Cleland, J., et al. (2007). Patient safety: Helping medical students understand error in healthcare. Quality & Safety in Health Care, 16(4), 256–259.

    Article  Google Scholar 

  • Pfeiffer, Y., & Wehner, T. (2012). Incident reporting systems in hospitals: How does learning occur using this organisational instrument? In J. Bauer & C. Harteis (Eds.), Human fallibility: The ambiguity of errors. Dordrecht: Springer Science + Business Media.

    Google Scholar 

  • Pham, J. C., Gianci, S., Battles, J., Beard, P., Clarke, J. R., Coates, H., et al. (2010). Establishing a global learning community for incident-reporting systems. Quality and Safety in Health Care, 19(5), 446–451.

    Article  Google Scholar 

  • Pierluissi, E., Fischer, M. A., Campbell, A. R., & Landefeld, C. S. (2003). Discussion of medical errors in morbidity and mortality conferences. JAMA, the Journal of the American Medical Association, 290(21), 2838–2842.

    Article  Google Scholar 

  • Pletcher, S. N., & Rodi, S. W. (2011). Web-based morbidity and mortality conferencing: A model for rural medical education. Journal of Continuing Education in the Health Professions, 31(2), 128–133.

    Article  Google Scholar 

  • Prince, J. M., Vallabhaneni, R., Zenati, M. S., Hughes, S. J., Harbrecht, B. G., Lee, K. K., et al. (2007). Increased interactive format for morbidity & mortality conference improves educational value and enhances confidence. Journal of Surgical Education, 64(5), 266–272.

    Article  Google Scholar 

  • Reagans, R., Argote, L., & Brooks, D. (2005). Individual experience and experience working together: Predicting learning rates from knowing who knows what and knowing how to work together. Management Science, 51(6), 869–881.

    Article  Google Scholar 

  • Reason, J. (1995). Understanding adverse events: Human factors. Quality in Health Care, 4(2), 80–89.

    Article  Google Scholar 

  • Risucci, D. A., Sullivan, T., DiRusso, S., & Savino, J. A. (2003). Assessing educational validity of the morbidity and mortality conference: A pilot study. Current Surgery, 60(2), 204–209.

    Article  Google Scholar 

  • Rosen, P., Edlich, R. F., Rosen, C. L., & Wolfe, R. E. (2008). Becoming a specialist in emergency medicine. The Journal of Emergency Medicine, 34(4), 471–476.

    Article  Google Scholar 

  • Rosenfeld, J. C. (2005). Using the morbidity and mortality conference to teach and assess the ACGME general competencies. Current Surgery, 62(6), 664–669.

    Article  Google Scholar 

  • Seigel, T. A., McGillicuddy, D. C., Barkin, A. Z., & Rosen, C. L. (2010). Morbidity and mortality conference in emergency medicine. The Journal of Emergency Medicine, 38(4), 507–511.

    Article  Google Scholar 

  • Sessa, V. I., & London, M. (2006). Continuous learning in organizations. Individual, group and organizational perspectives. Mahwah, NJ: Lawrence Erlbaum Associates.

  • Sevdalis, N., Jacklin, R., Arora, S., Vincent, C. A., & Thomson, R. G. (2010). Diagnostic error in a national incident reporting system in the UK. Journal of Evaluation in Clinical Practice, 16(6), 1276–1281.

    Article  Google Scholar 

  • Skule, S. (2004). Learning conditions at work: A framework to understand and assess informal learning in the workplace. International Journal of Training and Development, 8(1), 8–20.

    Article  Google Scholar 

  • Staton, L. J., Kraemer, S. M., Patel, S., Talente, G. M., & Estrada, C. A. (2007). Peer chart audits: A tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement. Implement Science, 2, 24.

    Article  Google Scholar 

  • Stergiopoulos, V., Maggi, J., & Sockalingam, S. (2010). Teaching and learning the physician manager role: Psychiatry residents’ perspectives. Medical Teacher, 32(7), e308–e314.

    Article  Google Scholar 

  • Sultana, C. J., & Baxter, J. K. (2011). A resident conference for systems-based practice and practice-based learning. Obstetrics and Gynecology, 117(2 Pt 1), 377–382.

    Article  Google Scholar 

  • Tamuz, M., Thomas, E. J., & Franchois, K. E. (2004). Defining and classifying medical error: Lessons for patient safety reporting systems. Quality and Safety in Health Care, 13(1), 13–20.

    Article  Google Scholar 

  • Tannenbaum, S. I., Beard, R. L., McNall, L. A., & Salas, E. (2010). Informal learning and development in organizations. In S. W. J. Kozlowski & E. Salas (Eds.), Learning, training, and development in organizations (pp. 303–329). New York, NY: Routledge.

    Google Scholar 

  • Thomas, E., & Petersen, L. (2003). Measuring errors and adverse events in health care. Journal of General Internal Medicine, 18(1), 61–67.

    Article  Google Scholar 

  • Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T., Williams, E. J., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care, 38(3), 261–271.

    Article  Google Scholar 

  • Waring, J. J., & Bishop, S. (2010). “Water cooler” learning: Knowledge sharing at the clinical “backstage” and its contribution to patient safety. Journal of Health Organization and Management, 24(4), 325–342.

    Google Scholar 

  • Weaver, S. J., Lyons, R., DiazGranados, D., Rosen, M. A., Salas, E., Oglesby, J., et al. (2010). The anatomy of health care team training and the state of practice: A critical review. Academic Medicine, 85(11), 1746–1760.

    Google Scholar 

  • Weingart, S., Pagovich, O., Sands, D., Li, J., Aronson, M., Davis, R., et al. (2005). What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. Journal of General Internal Medicine, 20(9), 830–836.

    Article  Google Scholar 

  • Weissman, J. S., Schneider, E. C., Weingart, S. N., Epstein, A. M., David-Kasdan, J., Feibelmann, S., et al. (2008). Comparing patient-reported hospital adverse events with medical record review: Do patients know something that hospitals do not? Annals of Internal Medicine, 149(2), 100–108.

    Article  Google Scholar 

  • Wofford, M. M., Wofford, J. L., Bothra, J., Kendrick, S. B., Smith, A., & Lichstein, P. R. (2004). Patient complaints about physician behaviors: A qualitative study. Academic Medicine, 79(2), 134–138.

    Article  Google Scholar 

  • Ziegelstein, R. C., & Fiebach, N. H. (2004). “The Mirror” and “The Village”: A new method for teaching practice-based learning and improvement and systems-based practice. Academic Medicine, 79(1), 83–88.

    Article  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Tim Dornan for editing the final version of the manuscript.

Author information

Affiliations

  1. Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands

    Jeantine M. de Feijter & Willem S. de Grave

  2. Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands

    Richard P. Koopmans

  3. Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

    Albert J. J. A. Scherpbier

Authors
  1. Jeantine M. de Feijter
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Willem S. de Grave
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richard P. Koopmans
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Albert J. J. A. Scherpbier
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeantine M. de Feijter.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

de Feijter, J.M., de Grave, W.S., Koopmans, R.P. et al. Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. Adv in Health Sci Educ 18, 787–805 (2013). https://doi.org/10.1007/s10459-012-9400-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10459-012-9400-1

Keywords

  • Medical error
  • Informal learning
  • Morbidity and mortality conference
  • Incident reporting system
  • Patient complaints
  • Chart review
  • Prospective risk analysis