Amy C. Edmondson

Psychological Safety and Learning Behavior in Work Teams

This paper presents a model of team learning and tests it in a multimethod field study. It introduces the construct of team psychological safety—a shared belief held by members of a team that the team is safe for interpersonal risk taking—and models the effects of team psychological safety and team efficacy together on learning and performance in organizational work teams. Results of a study of 51 work teams in a manufacturing company, measuring antecedent, process, and outcome variables, show that team psychological safety is associated with learning behavior, but team efficacy is not, when controlling for team psychological safety. As predicted, learning behavior mediates between team psychological safety and team performance. The results support an integrative perspective in which both team structures, such as context support and team leader coaching, and shared beliefs shape team outcomes.

Disrupted Routines: Team Learning and New Technology Implementation in Hospitals

This paper reports on a qualitative field study of 16 hospitals implementing an innovative technology for cardiac surgery. We examine how new routines are developed in organizations in which existing routines are reinforced by the technological and organizational context All hospitals studied had top-tier cardiac surgery departments with excellent reputations and patient outcomes yet exhibited striking differences in the extent to which they were able to implement a new technology that required substantial changes in the operating-room-team work routine. Successful implementers underwent a qualitatively different team learning process than those who were unsuccessful. Analysis of qualitative data suggests that implementation involved four process steps: enrollment, preparation, trials, and reflection. Successful implementers used enrollment to motivate the team, designed preparatory practice sessions and early trials to create psychological safety and encourage new behaviors, and promoted shared meaning and process improvement through reflective practices. By illuminating the collective learning process among those directly responsible for technology implementation, we contribute to organizational research on routines and technology adoption.

Speaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams

This paper examines learning in interdisciplinary action teams. Research on team effectiveness has focused primarily on single-discipline teams engaged in routine production tasks and, less often, on interdisciplinary teams engaged in discussion and management rather than action. The resulting models do not explain differences in learning in interdisciplinary action teams. Members of these teams must coordinate action in uncertain, fast-paced situations, and the extent to which they are comfortable speaking up with observations, questions, and concerns may critically influence team outcomes. To explore what leaders of action teams do to promote speaking up and other proactive coordination behaviours - as well as how organizational context may affect these team processes and outcomes - I analysed qualitative and quantitative data from 16 operating room teams learning to use a new technology for cardiac surgery. Team leader coaching, ease of speaking up, and boundary spanning were associated with successful technology implementation. The most effective leaders helped teams learn by communicating a motivating rationale for change and by minimizing concerns about power and status differences to promote speaking up in the service of learning. Copyright Blackwell Publishing Ltd 2003.

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

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.

Incidence and preventability of adverse drug events in nursing homes

PURPOSE Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes. METHODS We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium. RESULTS During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events. CONCLUSIONS Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.

OBJECTIVES To compare the frequency and preventability of adverse drug events and potential adverse drug events in intensive care units (ICUs) and non-ICUs. To evaluate systems factors involving the individual caregivers, care unit teams, and patients involved in each adverse drug event by comparing ICUs with non-ICUs and medical ICUs with surgical ICUs. DESIGN Prospective cohort study. Participants included all 4,031 adult admissions to a stratified, random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical ICUs and four medical and two surgical general care units. SETTING Two tertiary care hospitals: Eleven medical and surgical units, including two medical and three surgical ICUs. PATIENTS Adult admissions (n = 4,031). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Rate of preventable adverse drug events and potential adverse drug events, length of stay, charges, costs, and measures of the units environment. Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented adverse drug events or potential adverse drug events and as to severity and preventability. Those individuals involved in the preventable adverse drug event and potential adverse drug event underwent detailed interviews by peer case-investigators. The rate of preventable adverse drug events and potential adverse drug events in ICUs was 19 events per 1000 patient days, nearly twice that rate of non-ICUs (p <.01). The medical ICU rate (25 events per 1000 patient days) was significantly (p <.05) higher than the surgical ICU rate (14 events per 1000 patient days). When adjusted for the number of drugs used in the previous 24 hrs or ordered since admission, there were no differences in rates between ICUs and non-ICUs. ICU acuity, length of stay, and severity of the adverse drug event were greater in ICUs than non-ICUs, but there were no differences between medical ICU and surgical ICU patients. Structured interviews indicated almost no differences between ICUs and non-ICUs for many characteristics of the patient, patient care team, systems, and individual caregivers. CONCLUSIONS The rate of preventable and potential adverse drug events was twice as high in ICUs compared with non-ICUs. However, when adjusted for the number of drugs ordered, there was no greater likelihood for preventable adverse drug events and potential adverse drug events to occur in ICUs than in non-ICUs. Preventable adverse drug events and potential adverse drug events occurred in units that functioned normally and involved caregivers who were working under reasonably normal circumstances, not at the extremes of workload, stress, or a difficult environment.

Learning How and Learning What: Effects of Tacit and Codified Knowledge on Performance Improvement Following Technology Adoption

This paper examines effects of tacit and codified knowledge on performance improvement as organizations gain experience with a new technology. We draw from knowledge management and learning curve research to predict improvement rate heterogeneity across organizations. We first note that the same technology can present opportunities for improvement along more than one dimension, such as efficiency and breadth of use. We compare improvement for two dimensions: one in which the acquisition of codified knowledge leads to improvement and another in which improvement requires tacit knowledge. We hypothesize that improvement rates across organizations will be more heterogeneous for dimensions of performance that rely on tacit knowledge than for those that rely on codified knowledge (H1), and that group membership stability predicts improvement rates for dimensions relying on tacit knowledge (H2). We further hypothesize that when performance relies on codified knowledge, later adopters should improve more quickly than earlier adopters (H3). All three hypotheses are supported in a study of 15 hospitals learning to use a new surgical technology. Implications for theory and practice are discussed.

Learning from failure in health care: frequent opportunities, pervasive barriers

The notion that hospitals and medical practices should learn from failures, both their own and others’, has obvious appeal. Yet, healthcare organisations that systematically and effectively learn from the failures that occur in the care delivery process, especially from small mistakes and problems rather than from consequential adverse events, are rare. This article explores pervasive barriers embedded in healthcare’s organisational systems that make shared or organisational learning from failure difficult and then recommends strategies for overcoming these barriers to learning from failure, emphasising the critical role of leadership. Firstly, leaders must create a compelling vision that motivates and communicates urgency for change; secondly, leaders must work to create an environment of psychological safety that fosters open reporting, active questioning, and frequent sharing of insights and concerns; and thirdly, case study research on one hospital’s organisational learning initiative suggests that leaders can empower and support team learning throughout their organisations as a way of identifying, analysing, and removing hazards that threaten patient safety.

6 Three Perspectives on Team Learning: Outcome Improvement, Task Mastery, and Group Process

Abstract The emergence of a research literature on team learning has been driven by at least two factors. First, longstanding interest in what makes organizational work teams effective leads naturally to questions about how members of newly formed teams learn to work together and how existing teams improve or adapt. Second, some have argued that teams play a crucial role in organizational learning. These interests have produced a growing and heterogeneous literature. Empirical studies of learning by small groups or teams present a variety of terms, concepts, and methods. This heterogeneity is both generative and occasionally confusing. We identify three distinct areas of research that provide insight into how teams learn to stimulate cross-area discussion and future research. We find that scholars have made progress in understanding how teams in general learn, and propose that future work should develop more precise and context-specific theories to help guide research and practice in disparate task and in...

When problem solving prevents organizational learning

We propose that research on problem‐solving behavior can provide critical insight into mechanisms through which organizations resist learning and change. In this paper, we describe typical front‐line responses to obstacles that hinder workers’ effectiveness and argue that this pattern of behavior creates an important and overlooked barrier to organizational change. Past research on quality improvement and problem solving has found that the type of approach used affects the results of problem‐solving efforts but has not considered constraints that may limit the ability of front‐line workers to use preferred approaches. To investigate actual problem‐solving behavior of front‐line workers, we conducted 197 hours of observation of hospital nurses, whose jobs present many problem‐solving opportunities. We identify implicit heuristics that govern the problem‐solving behaviors of these front‐line workers, and suggest cognitive, social, and organizational factors that may reinforce these heuristics and thereby prevent organizational change and improvement.