Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change

T !ie importance of hospitals learning from tlieir 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.' Organizational learning is thus an imperative. Recent research suggests there are plenty of problems, errors, and other learning opportunities lacing these complex service organizations. In 2000, the Institute of Medicine issued a report estimating that 44,000 to 98,000 people die each year as a result of medical errors.^ Other studies suggest, in addition, that medical errors with less serious consequences are pervasive in hospitals.^