Implementation challenges of electronic blood transfusion safety systems: Lessons from an international, multi-site comparative case study.

BACKGROUND: Severe transfusion reactions resulting from errors in matching the correct blood with the correct patient are considered never events. Despite the relative technical simplicity of barcode scanning for patient-blood bag matching, the adoption and universal application of this safety measure are by no means universal. This study highlights the logistical and institutional challenges associated with spreading, scaling up, and sustaining such IT-supported safety measures in healthcare. STUDY DESIGN AND METHODS: We report findings from a 5-year, prospective, multi-site case study conducted across one hospital in England and three hospitals in the Netherlands. Ethnographic methods, including interviews and observations, were used at each site to investigate the implementation of barcode scanning-supported safety pathways for blood transfusions. RESULTS: Significant variation was observed across the sites in the adoption and implementation of barcode scanning-supported safety pathways. Despite the potential for reducing transfusion errors, the introduction of this innovation was met with varying levels of success in different settings. DISCUSSION: This study highlights the critical role of inter-hospital learning and flexible system design in successfully implementing barcode scanning-supported safety pathways for blood transfusions. A more structured, national-level network for knowledge sharing could enhance the spread and sustainability of such innovations across healthcare settings.

Interactions between the context of a health-care organisation and failure: the situational impact of failure on organisational learning.

PURPOSE: This study aims to explore how health-care organisations learn from failures, challenging the common view in management science that learning is a continuous cycle. It focuses on understanding how the context of a health-care organisation and the characteristics of failure interact. DESIGN/METHODOLOGY/APPROACH: Systematically collected empirical studies that examine how health-care organisations react to failures, both in terms of learning and non-learning, were reviewed and analysed. The key characteristics of failures and contextual factors are categorised at the individual, team, organisational and global level. FINDINGS: Several factors across four distinct levels are identified as being susceptible to the situational impact of failure. In addition, these factors can be used in the design and development of innovations. Taking these factors into account is expected to stimulate learning responses when an innovation does not succeed. This enhances the understanding of how health-care organisations learn from failure, showing that learning behaviour is not solely dependent on whether a health-care organisation possesses the traits of a learning organisation or not. ORIGINALITY/VALUE: This review offers a new perspective on organisational learning, emphasising the situational impact of failure and how learning occurs across different levels. It distinguishes between good and bad failures and their effects on a health-care organisation's ability to learn. Future research could use these findings to study how failures influence organisational performance over time, using longitudinal data to track changes in learning capacity.