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Logo of qualsafetyQuality and Safety in Health CareCurrent TOCInstructions for authors
Qual Saf Health Care. Dec 2004; 13(Suppl 2): ii3–ii9.
PMCID: PMC1765808

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


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.

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Selected References

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  • Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med. 1997 Aug;25(8):1289–1297. [PubMed]
  • Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T, Hallisey R, Ives J, Laird N, Laffel G, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):35–43. [PubMed]
  • Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995 Apr;10(4):199–205. [PubMed]
  • Nelson Eugene C, Batalden Paul B, Homa Karen, Godfrey Marjorie M, Campbell Christine, Headrick Linda A, Huber Thomas P, Mohr Julie J, Wasson John H. Microsystems in health care: Part 2. Creating a rich information environment. Jt Comm J Qual Saf. 2003 Jan;29(1):5–15. [PubMed]
  • Leape LL. Error in medicine. JAMA. 1994 Dec 21;272(23):1851–1857. [PubMed]
  • Hansten RI, Washburn MJ. Individual and organizational accountability for development of critical thinking. J Nurs Adm. 1999 Nov;29(11):39–45. [PubMed]
  • Lee JL, Chang BL, Pearson ML, Kahn KL, Rubenstein LV. Does what nurses do affect clinical outcomes for hospitalized patients? A review of the literature. Health Serv Res. 1999 Dec;34(5 Pt 1):1011–1032. [PMC free article] [PubMed]
  • Taylor C. Problem solving in clinical nursing practice. J Adv Nurs. 1997 Aug;26(2):329–336. [PubMed]
  • Aiken LH, Patrician PA. Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nurs Res. 2000 May-Jun;49(3):146–153. [PubMed]
  • Carroll JS, Edmondson AC. Leading organisational learning in health care. Qual Saf Health Care. 2002 Mar;11(1):51–56. [PMC free article] [PubMed]

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