Speaker
Description
Background: Errors in treatment are frequently reported through approaches that prioritize individual actions over system- level factors, contributing to fear of blame, limiting meaningful organizational improvement, and reducing opportunities for learning and prevention (Hibbert et al., 2025; Wawersik et al., 2023). At Niagara Region Public Health, error reporting relied on paper forms and manual spreadsheet tracking, resulting in inconsistent data, limited analytic capacity, and reduced opportunities for organizational learning and prevention within a large, multi-program public health nursing context.
Aim: Design and implement a system focused approach to learning from errors in treatment that improves reporting consistency, supports nurses, and enables sustainable improvement in public health nursing practices.
Implementation approach: A quality improvement initiative guided by RNAO’s Leading Change Toolkit and informed by the Knowledge-to-Action (KTA) Framework was undertaken in collaboration with leaders, professional practice supports and an MPH student. Ten years of error data were retrospectively analyzed to identify system contributors and high-risk processes. Implementation strategies included revising policies and occurrence-reporting tools, removing punitive language, clarifying expectations for reporting, and tailoring change approaches to local context and workforce readiness. Exploration of digital reporting solutions has been initiated to support future analysis.
Outcomes: This foundational phase produced standardized terminology and data structures, establishment of baseline trend data, identification of recurring system‑level learning themes, and leadership‑endorsed recommendations for practice and process changes. Updated policy and occurrence‑reporting tools will be developed to support future evaluation. Early feedback from nursing leadership suggests increased organizational readiness to shift toward a consistent, non‑punitive, and system‑focused approach to learning from errors.
Implications for practice: System-level error‑learning initiatives require intentional language, leadership alignment, and pragmatic evaluation approaches. Applying structured change frameworks supports a shift from individual blame to system learning while promoting equity, accessibility, and culturally safe learning environments for nurses.
Author(s) Credentials and Title
Beverley Richter, RN, BScN, MSc, CCHN(C), Nursing Practice Specialist; Diane Vanecko, RN, BScN, MBA, Director of Clinical Services and Chief Nursing Officer; Suleman Dahya, BHSc, Practicum Student and MPH Candidate.
What RNAO BPG or tool/toolkit is your abstract related to?
Leading Change Toolkit; Knowledge-To-Action Framework
| Organization Name | Niagara Region Public Health |
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