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PSNet: Patient Safety Network
Journal Article

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.

Edmondson AC. The Journal of Applied Behavioral Science. 2006;32.

Edmondson proposes that, rather than examining errors and accidents in health care on an individual or system level, we should instead focus on teams of individuals within organizations. The study, conducted on eight individual floors (units) at a university hospital, analyzes how differences in work group properties are associated with different error rates. Team members were surveyed to determine the social and organizational properties of the units, and an individual researcher also blindly observed nursing teams to qualitatively describe the behavioral dynamics. The study found that units with stronger nurse manager direction, coaching, perceived unit performance, and quality of unit relationship had significantly higher rates of medication errors. The author postulates that detected error rates are dependent both on the actual error rates and the rate of reporting. Managers within an organization must design and nurture work environments that encourage error reporting and fostering learning from mistakes to avoid repeating them in the future.