PT  - JOURNAL ARTICLE
AU  - Edmondson, A C
TI  - Learning from failure in health care: frequent opportunities, pervasive barriers
AID  - 10.1136/qshc.2003.009597
DP  - 2004 Dec 01
TA  - Quality and Safety in Health Care
PG  - ii3--ii9
VI  - 13
IP  - suppl 2
4099  - http://qualitysafety.bmj.com/content/13/suppl_2/ii3.short
4100  - http://qualitysafety.bmj.com/content/13/suppl_2/ii3.full
SO  - Qual Saf Health Care2004 Dec 01; 13
AB  - 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.