Learning from failure in health care: frequent opportunities, pervasive barriers

被引:257
作者
Edmondson, AC [1 ]
机构
[1] Harvard Univ, Sch Business, Boston, MA 02163 USA
来源
QUALITY & SAFETY IN HEALTH CARE | 2004年 / 13卷
关键词
D O I
10.1136/qshc.2003.009597
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
The notion that hospitals and medical practices should learn from failures, both their own and others'. has obvious appeal. Yet, healthcare organisations that systematically and effectively learn from the failures that occur in the care delivery process, especially from small mistakes and problems rather than from consequential adverse events, are rare. This article explores pervasive barriers embedded in healthcare's organisational systems that make shared or organisational learning from failure difficult and then recommends strategies for overcoming these barriers to learning from failure, emphasising the critical role of leadership. Firstly, leaders must create a compelling vision that motivates and communicates urgency for change; secondly, leaders must work to create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns; and thirdly, case study research on one hospital's organisational learning initiative suggests that leaders can empower and support team learning throughout their organisations as a way of identifying, analysing, and removing hazards that threaten patient safety.
引用
收藏
页码:3 / 9
页数:7
相关论文
共 40 条
[21]  
HACKMAN JR, 2003, TEAM DIAGNOSTIC SURV
[22]   Individual and organizational accountability for development of critical thinking [J].
Hansen, RI ;
Washburn, NJ .
JOURNAL OF NURSING ADMINISTRATION, 1999, 29 (11) :39-45
[23]  
HELMREICH RL, 1991, AIAA NASA FAA HFS C
[24]   ERROR IN MEDICINE [J].
LEAPE, LL .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1994, 272 (23) :1851-1857
[25]  
Lee JL, 1999, HEALTH SERV RES, V34, P1011
[26]  
LEOPE LL, 1995, JAMA-J AM MED ASSOC, V274, P35
[27]  
MOSS M, 2002, NY TIMES 1210, P1
[28]  
Orr J., 1996, TALKING MACHINES
[29]   Capability traps and self-confirming attribution errors in the dynamics of process improvement [J].
Repenning, NP ;
Sterman, JD .
ADMINISTRATIVE SCIENCE QUARTERLY, 2002, 47 (02) :265-295
[30]  
SITKIN SB, 1992, RES ORGAN BEHAV, V14, P231