2003/01/01 by Anita L. Tucker, Amy C. Edmondson · 928 citations
Business, Management and Accounting · Decision Sciences · Psychology · #Business #Complex Systems and Decision Making #Computer science #Economics #Field (mathematics) #Front line #Marketing #Operations management #Organizational Learning and Leadership #Organizational change #Political science #Process (computing) #Process management #Psychology #Public relations #Quality and Supply Management #Service (business)
paper · doi:10.2307/41166165
published in California Management Review 45(2), 55-72 (SAGE Publishing)
openalex publication_date 2003/01/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/08/03
The importance of hospitals learning from their failures hardly needs to be stated. Not only are matters of life and death at stake on a daily basis, but also an increasing number of U.S. hospitals are operating in the red. This article reports on in-depth qualitative field research of nurses' responses to process failures in nine hospitals. It identifies two types of process failures—errors and problems—and discusses implications of each for process improvement. A dynamic model of the system in which front-line workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than driving learning and change in hospitals. Three managerial levers for change are identified, suggesting a new strategy for improving hospitals' and other service organizations' ability to learn from failure.