Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error

Journal of Applied Behavioral Science, The - Tập 32 Số 1 - Trang 5-28 - 1996
Amy C. Edmondson1
1Harvard University

Tóm tắt

This research explores how group- and organizational-level factors affect errors in administering drugs to hospitalized patients. Findings from patient care groups in two hospitals show systematic differences not just in the frequency of errors, but also in the likelihood that errors will be detected and learned from by group members. Implications for learning in and by work teams in general are discussed.

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Tài liệu tham khảo

Alderfer, C., 1987, Handbook of organizational behavior

Argyris, C., 1985, Strategy, change, and defensive routines

Barker, K. N., 1962, American Journal of Hospital Pharmacy, 19, 361

10.1007/BF02600255

10.1007/BF02600138

10.1001/jama.1991.03470200059035

Cohen, M. R., 1977, American Journal of Hospital Pharmacy, 12, 42

Evans, R. S., Proceedings of the Annual Symposium on Computerized Applications for Medical Care, 23

Fiske, S. T., 1991, Social cognition

Forrester, J. W., 1971, Technology Review, 73, 52

Foushee, H. C., 1986, Crew factors in flight operations III: The operational significance of exposure to short-haul air transport operations

Goleman, D., 1985, Vital lies simple truths: The psychology of self-deception

Hackman, J. R., 1987, Handbook of organizational behavior

Hackman, J. R., proceedings of the ICAO Human Factors Seminar

Hackman, J. R., 1993, Cockpit resource management

Hackman, J. R., 1975, Small groups and social interaction

Helmreich, R. L., 1993, Cockpit resource management

10.1037/0021-9010.69.1.85

10.1037/0022-3514.48.2.339

10.1056/NEJM199102073240605

Lesar, T. S., 1990, Journal of American Medicine, 263, 2329

10.1080/00224545.1939.9713366

10.1037/h0024737

10.1097/00001888-199301000-00004

10.1056/NEJM197106172842408

Michael, D. N., 1976, On learning to plan and planning to learn

Norman, D. A., 1980, Psychology Today, 13, 42

10.1037/0033-295X.88.1.1

Perrow, C., 1984, Normal accidents

Reason, J., 1984, Varieties of attention, 515

Rice, A. K., 1958, Productivity and social organization: The Ahmedabad experiment

Roethlisberger, F. J., 1939, Management and the worker

Rumelhart, D. E., 1980, Theoretical issues in reading comprehension: Perspectives from cognitive psychology, linguistics, artificial intelligence and education, 33

Senge, P., 1990, The fifth discipline: The art and practice of the learning organization

10.1177/001872675100400101