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Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Review
Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.
The authors reviewed the literature on teamwork and communication initiatives from aviation and assessed the impact of these practices on safety in the perinatal setting.
Journal Article > Study
Hoff TJ, Pohl H, Bartfield J. J Org Behav. 2006;27:869-896.
This AHRQ–funded study directly observed residents and attendings in the medical intensive care unit and trauma surgery services at an academic medical center with the goal of examining responses to errors and near misses. The authors analyzed the positive and negative aspects of specific features of the physician work culture, including the "aloofness" of attending physicians, the emphasis on avoiding "surprises" in discussing clinical information, and "pimping" of residents by attendings. Although multiple errors and near misses were observed, these were generally not used as learning opportunities, as has been found in prior research. Specific techniques that encourage a learning culture, such as providing feedback and encouraging inquiry, were rarely used in response to errors.
Journal Article > Study
Matthews JI, Thomas PT. Int J Health Care Qual Assur. 2007;20:184-194.
The investigators interviewed clinicians and managers to assess how knowledge is captured in a clinical setting. They found that mechanistic reporting processes may compromise more organic methods of organizational learning.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.