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Good catches, better care learning from near misses in the hospital Eda Algur
- Format:
- Book
- Thesis/Dissertation
- Author/Creator:
- Algur, Eda, author.
- Language:
- English
- Subjects (All):
- Public health.
- Psychology.
- Nursing.
- 0769.
- 0621.
- 0569.
- 0573.
- Local Subjects:
- Public health.
- Psychology.
- Nursing.
- 0769.
- 0621.
- 0569.
- 0573.
- Genre:
- Academic theses
- Physical Description:
- 1 online resource (208 pages)
- Contained In:
- Dissertations Abstracts International 87-12B
- Place of Publication:
- Ann Arbor : ProQuest Dissertations and Theses, 2026
- Language Note:
- English
- Summary:
- Near misses, errors detected and corrected before reaching the patient, are among healthcare's most frequent and most underutilized safety signals. This dissertation examines how individuals and teams learn from near misses across three papers using qualitative interviews, shift-level panel data, and medication order records from a large academic health system. Chapter 2 finds that while near misses and errors share the same root causes and produce the same learning outcomes, the learning process diverges across four dimensions (emotional response, timing, locus, and relational autonomy), positioning near misses as a more favorable and distinct learning context than errors. Chapter 3 documents an inverted-U learning curve for near misses: accumulated near miss exposure initially increases error-catching but eventually this relationship fades, with provider experience steepening early learning without preventing eventual attenuation. Chapter 4 finds that collective team experience predicts error interception, while the effects of individual experience are conditional and suppressed in familiar and failure-bonded teams. This work establishes near misses as a theoretically and practically distinct learning context with real but perishable value. Realizing that value requires deliberate organizational investment in the team infrastructure and processes that keep weak signals alive long enough to do their work
- Notes:
- Source: Dissertations Abstracts International, Volume: 87-12, Section: B.
- Advisors: Nembhard, Ingrid Committee members: King, Marissa; Klein, Katherine; Song, Hummy; Friedman, Ari
- Ph.D. University of Pennsylvania 2026
- Vendor supplied data
- Local Notes:
- School code: 0175
- ISBN:
- 9798247979456
- Access Restriction:
- Restricted for use by site license
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