Article Text

Download PDFPDF

Learning from failure in health care: frequent opportunities, pervasive barriers
Free
  1. A C Edmondson
  1. Correspondence to:
 Dr A C Edmondson
 Harvard Business School, Harvard University, Boston, MA 02163, USA; aedmondsonhbs.edu

Abstract

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.

  • PSSC, Patient Safety Steering Committee
  • leadership
  • learning
  • mistakes
  • problem-solving
  • teams
  • PSSC, Patient Safety Steering Committee
  • leadership
  • learning
  • mistakes
  • problem-solving
  • teams

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.