Table 3.

Example of the analysis process regarding the nurses’ perception of SOPSB in learning from near misses.

The 4I Framework of Organization Learning	The meaning of the ‘4I framework’ from a frontline nurse perspective			Examples of participants’ narratives
Intuiting	Being a leader inexposingnear misses	Transmitting the message of near misses to corresponding parties	•Alerting colleagues of the occurrence of a near miss •Reporting near misses to managers •Letting the responsible people know a near-miss happened	• …if you do not expose the near misses that happened, managers will never be aware of the problem… • Many oral medicines look so similar…I call up or sometimes have a face-to-face talk with the pharmacists.
		Using different exposing strategies	•Making formal reports on serious near misses •Making informal chat on less serious near misses •Self-reflection on near misses that may result in punishment	• The bugs in the electronic ordering system may result in serious medication errors…we report it through the official reporting system. • If the near-miss is not that serious, I may not report to the head nurse…
		Optimizing the exposure effect	•Drawing manager’s attention by summarizing related data •Seeking help from superiors to expose near misses	• The managers will not take the reported near-misses seriously without any data… • I always turn to senior nurses for help…they take the senior nurses ’words more seriously.
Interpreting	Pushing forward the cause analysis withinlimitedcapacity	Searching forthein-depth explanationof near misses	•Underlying causes should be explored •Defects in the working system are critical	• I think the second-order problem solving behavior mainly refers to my responses to the causes…
		Regarding the cause analysis as thein-roleduty	•Nurses hold more information about why near misses occur •Nursing work includes the identification of error causes •Nurses concern about what cause near misses	•…nurses know more about why the near miss happened…This is a job that you have to do… • I was the only person who care about the near miss …
		Sharing causes with corresponding parties	•Key information about safety should be shared •Near misses are the results of multi-link faults •Reminding others not to make the same mistake	• …we use the WeChat group to let everyone in the unite know… • …win-win communication is necessary to make job much safer.
		Not being well prepared for the analysis work and need to seek help	•Nurses do not have knowledge, time and energy to analyze causes •Most analysis stay around superficial with formality •Asking for assistance to dig deeper into the causes	• …however, I do not have enough knowledge or time to do the analysis… • …the medication near misses are the results of individual carelessness…
		Being influenced by social support and working climate	•Causes analysis was identified as the managers’ business •Others do not care about the harmless near misses •Worrying about being perceived as a buck-passer	•Managers will analyze the causes, we nurses do not have to care too much… • …others may say you are trying to shift responsibility.
Integrating	Balancing the active and passive role during improvement project	Taking opportunities to make improvement suggestions	•Improving work is critical to prevent near misses •Suggesting possible improvement actions	• …only when the new measures be implemented in practice…learn something from near misses. • …I will discuss with the head nurse to see if we can try it at work.
		Having the new ideas be considered and tried out	•Explaining the new idea or measures to promote their application •Providing evidence of the necessity for improvement •Making near misses get a piece of management resources	• …it is necessary to explain your suggestion to prompt its application… • I prepared a simple payoff-risk report and suggested …
		Taking risks of showing much passion for work improvement	•Improving work is the duty of managers •Being mistaken for a person who swerves from own duty •Few colleagues are willing to change the existing working habit	• …it is improperly for me to point a finger at the improvement issue… • …no one wants to change the conventional working process…
		Expecting more chances and autonomy during improvement process	•Nurses’ will to actively participate in work improvement •Nurses’ role is limited to making suggestions •Lacking of autonomy and voice in improvement work	• …we are expected to complete the task as required, regardless of the personal willingness or autonomy…
Institutionalizing	Promoting continuous improvement with passion while feeling low-powered	Emphasizing the follow-up actions to guarantee the improvement effects	•Concerning about the improvement effects •Solving new emerging problems during improvement •Giving feedback on the improvement effect	• …the value of frontline nurses mainly reflected on evaluating the actual effect of these improvement actions… • …inform the managers of how the new measures progress
		Feeling low-powered about the continuous improvement	•Nurses are content with the short-term effects •Unable to evaluate the actual effect of the improvement action	• As long as the measures are implemented as planned, they indeed do have effects… •…patient-missingnear miss is caused by the incomplete handover…it is meaningless to improve the entrance guard system.