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Table 1 MaPSaF descriptors for “learning following an incident”

From: Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies

Level

Excerpt from descriptor

1 (“Pathological”)

No attempts are made to learn from incidents unless imposed by the pharmacy inspector.

2 (“Reactive”)

Little if any learning occurs, and what does occur is related only to the level of inconvenience experienced by the manager or head office.

3 (“Calculative”)

Some systems are in place to facilitate learning, but lessons are confined to specific local changes and not communicated across the organization.

4 (“Proactive”)

The pharmacy has a learning tradition and systems exist to share learning, such as reflection and audit. Members of staff are actively involved.

5 (“Generative”)

The pharmacy is committed to sharing learning and information across the organization. Improvements occur without being triggered by an incident.