Codifying knowledge to improve patient safety: a qualitative study of practice-based interventions

Area of Science:

• Healthcare Management
• Patient Safety
• Knowledge Management

Background:

• Health professionals utilize both tacit and codified knowledge in patient care.
• Limited understanding exists on integrating these knowledge types for patient safety improvements.

Purpose of the Study:

• To investigate how combining tacit and codified knowledge supports patient safety.
• To examine the co-design and implementation of knowledge codification interventions in two NHS hospitals.

Main Methods:

• Qualitative study involving observation of mortality and morbidity (M&M) meetings and feedback sessions.
• Interviews with front-line clinicians and hospital managers.
• Implementation of a structured mortality review process and a medication safety scorecard.

Main Results:

• Knowledge codification facilitated learning at the front-line service level by structuring tacit knowledge sharing.
• Professional and managerial boundaries at the organizational level impacted the implementation of codification initiatives.
• Challenges in knowledge codification exist at group and organizational levels.

Conclusions:

• Translating knowledge across different organizational levels for patient safety improvement requires enabling factors.
• Alignment between clinical practice learning and governance is crucial for successful knowledge codification.
• Codifying knowledge presents distinct challenges requiring organizational support for effective implementation.