The Health Care Manager

Volume 25, Number 4, pp. 292–305

# 2006, Lippincott Williams & Wilkins, Inc.

An Organizational Approach to
Understanding Patient Safety and
Medical Errors
Amer Kaissi, PhD
Progress in patient safety, or lack thereof, is a cause for great concern. In this article, we argue
that the patient safety movement has failed to reach its goals of eradicating or, at least,
significantly reducing errors because of an inappropriate focus on provider and patient-level
factors with no real attention to the organizational factors that affect patient safety. We describe
an organizational approach to patient safety using different organizational theory perspectives
and make several propositions to push patient safety research and practice in a direction that is
more likely to improve care processes and outcomes. From a Contingency Theory perspective,
we suggest that health care organizations, in general, operate under a misfit between
contingencies and structures. This misfit is mainly due to lack of flexibility, cost containment,
and lack of regulations, thus explaining the high level of errors committed in these organizations.
From an organizational culture perspective, we argue that health care organizations must change
their assumptions, beliefs, values, and artifacts to change their culture from a culture of blame to a
culture of safety and thus reduce medical errors. From an organizational learning perspective, we
discuss how reporting, analyzing, and acting on error information can result in reduced errors in
health care organizations. Key words: contingency theory, organizational culture, organiza-
tional learning, organizational theory, patient safety

N 1999, THE Institute of Medicine (IOM)
I published the report ‘‘To Err is Human’’ in
which it estimated that around 45,000 to
98,000 Americans die each year because of
preventable medical errors.1 Immediately
after this publication, there was a surpris-
ingly rapid and strong response by the media,
the public, the president, key lawmakers,
and especially researchers. The health care
industry looked like it has just ‘‘discovered’’
the new epidemic of medical errors. Nearly 6
years after the report, there is ample evi-
dence that we are still far from reaching the
‘‘safe and reliable system that patients and
providers deserve.’’2 Wachter2 rates the pa-
tient safety movement on 5 main activities
From the Department of Health Care Administration,
Trinity University, San Antonio, Tex.
Correspondence: Amer Kaissi, PhD, Department
of Health Care Administration, One Trinity Place,
No 58, San Antonio, TX 78212 (e-mail:
amer.kaissi@trinity.edu).
292
and initiatives (regulation, reporting systems,
information technology, malpractice system,
and workforce issues) and concludes that the
overall effort is at the C+ level. Ronald
Berwick, a well-know health care quality
expert, is ‘‘disappointed by what he sees as a
lack of progress’’ in patient safety and notes
that ‘‘studies continue to show problem rates
nearly as high as those that started our
concerns.’’3 A recent study that evaluated
hospital patient safety systems found that the
development and implementation of these
systems is at best moderate and concluded
that ?the current status of hospital patient
safety systems is not close to meeting IOM’s
recommendations.’’4 Obviously, progress in
patient safety, or lack thereof, is a cause for
great concern. Consequently, health care
policy makers, providers, researchers, and
patients are asking: What can be done to
improve patient safety?
In this article, we argue that the patient
safety movement has failed to reach its goals of
eradicating or, at least, significantly reducing

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Understanding Patient Safety and Medical Errors
errors because of an inappropriate focus on
provider and patient-level factors with no real
attention to the organizational factors that
affect patient safety. A focus on latent errors,
that is, errors that are not in direct control of
front operators such as poor design, incorrect
installation, faulty maintenance, bad manage-
ment decisions, and poorly structured organi-
zations, rather than active errors that occur
at the level of frontline operators is highly
needed. We describe an organizational ap-
proach to patient safety using different organi-
zational theory perspectives and make several
propositions to push patient safety research
and practice in a direction that is more likely to
improve care processes and outcomes.
THE ORGANIZATIONAL APPROACH TO
UNDERSTANDING MEDICAL ERRORS
The rationale underlying our interest in
applying an organizational perspective to
improve the understanding of medical errors
is that the traditional concept of error in real-
world work situations must be replaced with
a more sophisticated understanding of the
performance of the entire organization rela-
tive to its explicit and implicit goals. This is
what is referred to as the system’s approach
to reducing medical errors. As defined by
Reason, a system is a set of interdependent
elements (human and nonhuman) interact-
ing to achieve a common aim.1 This ap-
proach views accidents as resulting from
large system failures, and thus looks at errors
as consequences and not causes, searching
for upstream systematic factors in the ‘‘blunt
end’’ as the origins of errors.5
A valuable schematic representation of the
System approach is the ‘‘Swiss cheese
model.’’ This model suggests that systems
have many defensive layers that are engi-
neered (alarms and physical barriers), rely on
people, or are made of procedures and
administrative controls. Ideally, each defen-
sive layer would be intact. However, in the
real world, the layers have holes (like those
found in Swiss cheese) that are continually
opening, shutting, and shifting their loca-
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
293
tions. An accident occurs only when the
holes in the many layers momentarily line up
to permit a trajectory of accident opportu-
nity. These holes are due either to active
failures or to latent conditions.
Active failures, as mentioned before, are
unsafe acts committed by people who are in
direct contact with the patient. They have a
direct and short-lived impact on the integrity
of the defenses. Latent conditions are inevi-
table ‘‘resident pathogens’’ in the system.
They lie dormant in the system for many
years before they combine with active fail-
ures to create an accident opportunity.
These active failures are the main focus of
the system approach that adopts a proactive
strategy in trying to identify and eliminate
them before they lead to accidents.
The interest in latent failures leading to
‘‘organizational accidents’’ is a result of the
belief that these accidents are really the only
kind left to happen in such complex,
automated, and well-defended systems such
as health care.6 Such systems are relatively
proof against single human or technical
failures at the sharp end. However, the
greatest risk is in their complexity, thus
leading to opaqueness: insidious accumula-
tion of latent failures that are hidden behind
computerized interfaces, obscured by the
layers of management or lost in the inter-
stices between various specialized depart-
ments. Thus, organizational accidents have
their origin in a variety of latent failures as-
sociated with organizational processes such as
designing, building, operating, maintaining,
communicating, and managing. In summary,
the etiology of organizational accidents thus
divides into 5 phases: ‘‘(a) organizational pro-
cesses giving rise to latent failures, (b) the
consequent creation of error- and violation-
producing conditions within specific work-
places (operating rooms, intensive care units,
pharmacies, etc), (c) the commission of errors
and violations by individuals carrying out
particular tasks at the sharp end, (d) events
in which 1 or more of the various defenses
and safeguards are breached or bypassed, and
(e) outcomes that can vary from free lesson
to a catastrophe.’’6
294 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
Complex organizations such as health care
delivery are composed of a series of hierar-
chically organized subsystems. These subsys-
tems include equipment, individuals, teams,
organizations, and environments (Fig. 1). At
the center of the system lie the physical
design of equipment and the immediate
work design such as the workstation layout,
displays, controls, lighting, and sound. On a
higher level is the presence of the individual,
that is, the single operator processing infor-
mation and making decisions on his own.
Factors affecting errors at this level include
decision making, educational level, motor
skills, perception, attention, thought, and
memory. However, most individuals in
health care achieve their work as part of
a team. Team factors include communica-
tion, coordination, cooperation, situation
awareness, assertiveness, leadership, deci-
sion making, adaptability, and planning.
Organizational behavior factors include
shift-work patterns, error reporting practi-
ces, safety culture, hierarchy of authority,
and goal setting. At the highest level, envi-
ronmental factors such as legal liability;
constraints on system design and work
practices; and political, institutional, and
economic pressure interact.1
Figure 1. Different levels of behavior affecting medical errors. Adopted and modified from Merritt and Helmreich.7
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
This article focuses mainly on the organi-
zational behavior perspective. Organizational
behavior affects the probability of error in
many general ways. At this level, policy and
managerial decisions are made, and they act
indirectly but powerfully downward to
impact individual and team behavior. At the
same time, policies and decisions themselves
are affected by legal and regulatory rules and
cultural and societal pressures operating
within the environment. Example of policies
and decisions include rules and programs,
delegation of autonomy, structural differen-
tiation, setting policies for shift work and
hours of work, investments in and quality
control over equipment, and the like.
In the following sections, we approach
medical errors from 3 different organizational
perspectives—Contingency Theory, Organiza-
tional Culture, and Organizational Learning—
and will try to integrate the benefits offered
by each of these approaches to enhance our
understanding of patient safety and medical
errors.
CONTINGENCY THEORY
Contingency Theory is an open system
view of environmental impacts on internal
 Understanding Patient Safety and Medical Errors
organizational structures, processes and
strategies, and a reaction to classical man-
agement theory and other closed system
perspectives. It is based on the general
premise that there is no best way to organize
and that any ways of organizing are not
equally effective. Thus, the best way to
organize is contingent on the environment.8
The various contingencies include the
organizational size, technology (production,
information), and environment (uncertainty,
resource munificence, and degree of competi-
tion) and constitute the context within which
the organization operates.9 Structure is defined
as both the officially prescribed formal organi-
zation and the de facto, unofficial formal
organization.10 It includes formalization, dif-
ferentiation, centralization, span of control,
specialization, etc. An important concept in
Contingency Theory is the concept of fit: a
tighter fit between context and structure
maximizes survival and performance.
It is argued that, as contingencies change,
organizations are in continuous search of the
structure that is most appropriate with the
change and that allows them to regain their
fit. This is highlighted by the Structural
Adaptation to Regain Fit model schematized
in figure 2.
Our application of Contingency Theory to
medical errors is based on the general
assumption that errors are due to system
failures and that part of that system is the
degree of fit between organizational struc-
tures and context. In other words, errors are
the result of lack of fit between structures
and context. Thus, for our purposes, organi-
zational effectiveness or performance is
conceptualized as the number of errors in
an organization.
Figure 2. Structural Adaptation to Regain Fit Model. Adopted and modified from Donaldson.10
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
295
The application of Contingency Theory to
the understanding of health care environ-
ments is not a new approach. For example,
Argote11 studied the interaction between
input uncertainty and organizational coordi-
nation and its effect on clinical efficiency in
emergency departments (EDs). Input uncer-
tainty was defined as the uncertainty on the
overall composition of patient inputs, such
as the number of patients in various con-
ditions, although organizational coordination
was defined as programmed coordination
(rules, schedules, meetings, authority ar-
rangements) versus nonprogrammed coordi-
nation (autonomy of members, general
policies, mutual adjustment). However, clini-
cal efficiency (a measure of organizational
effectiveness) was conceptualized as prompt-
ness of care, quality of nursing care, and
quality of medical care. The results indicated
that the use of programmed coordination
results in higher effectiveness in EDs that are
experiencing low uncertainty, whereas the
use of the nonprogrammed mean of coordi-
nation is most appropriate in EDs experienc-
ing high uncertainty.11 We suggest the use of
a similar approach with a level of error being
the measure of effectiveness.
Health care, especially the complex care
delivered by hospitals to treat serious dis-
eases, falls in the category of high-hazard
industries. High-hazard industries such as
aviation, shipping, electric power produc-
tion (nuclear power plants), chemical manu-
facturing, and the military are industries
that involve potent activities with the power
to kill or maim. We will try to understand
how these industries have dealt with their
contingencies to achieve fit and reduce
accidents and how does health care differ
296 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
from them in terms of contingencies, struc-
tures, and outcomes.
In general, there are 2 main theories of
organizational safety: Normal Accidents The-
ory, originally developed by sociologist Charles
Perrow (1984), and High Reliability Organiza-
tion Theory, developed by a group of re-
searchers at the University of California at
Berkeley.12 Combining these 2 theories results
in a contingency theory’s understanding of
safety.
Normal Accidents Theory focuses mainly
on 2 aspects of the system: complex
interactions (as opposed to linear ones) and
tight coupling (as opposed to loose cou-
pling). A system with complex interactions is
a system with unfamiliar, unplanned, unex-
pected, and invisible interactions with nu-
merous feedback loops and continuous
change from one sequence to another. In
contrary, linear interactions are visible,
expected, and familiar sequences. A system
with tight coupling of the interactions
between components or subsystems is a
system in which couplings are direct and
have short-time constants with few buffers to
slow down the interactions. Thus, what
happens in one item directly affects what
happens in another item with high time
dependency, unifinality, and little slack.
Thus, errors have dramatic effects. Loose
coupling, on the contrary, is characterized by
autonomy between items, possible delays,
equifinality, and great slack. The main
premise of Normal Accidents Theory is that
accidents are inevitable in complex and
tightly coupled systems. It advocates that
most of the efforts made at management and
design to prevent accidents tend to only
increase the opacity and complexity by
making more holes in the defense barriers,
therefore increasing the likelihood of acci-
dents. Thus, according to Normal Accidents
Theory, the combination of these factors
makes it inevitable that some of the normal
everyday faults, slips, and incidents will
result in tragic accidents.12
In contrast to this pessimistic view, High
Reliability Organization Theory views that
accidents can be prevented through good
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
organizational design and management. The
proper organization of people, technology,
and processes can handle complex and
hazardous activities at the acceptable levels
of performance. Thus, the concept of High
Reliability Organizations (HROs) emerged.
These are ‘‘systems operating in hazardous
conditions that have fewer than their share
of adverse events,’’5 have intrinsic safety
health, and are able to withstand their
operational dangers and still achieve their
objectives. Examples of HROs include nuclear
aircrafts, air traffic control systems, and nuclear
power plants. High Reliability Organizations
face many challenges such as managing
complex demanding technology to avoid fail-
ures and maintaining the capacity for meeting
periods of high-peak demand. They are com-
plex, internally dynamic, and intermittently,
intensely interactive, and they perform exact-
ing tasks under considerable time pressure.
The main distinguishing feature of HROs is
their ability to carry out these demanding
activities with low incident rates and an almost
complete absence of catastrophic failures over
several years. Although the above-mentioned
challenges and characteristics are highly similar
to health care organizations, the outcomes
vary substantially (IOM reports 45,000-98,000
deaths per year). Thus, it is suggested that
there are lessons to be learnt on health care
from these organizations. As suggested by the
IOM, ‘‘claims that healthcare is unique and
therefore not susceptible to a transfer of
learning from other industries are not support-
able.’’1 Moreover, the practices adopted by
other industries have resulted neither in stifled
innovation nor in loss of competitive benefit.
From a Contingency Theory perspective, these
organizations have managed to develop struc-
tures, processes, and strategies that allow them
to achieve fit with Perrow’s contingencies
(complexity and tight coupling) and with
other contingencies described by Thompson
and others (interdependence and uncertainty)
(see Fig. 3).
For example, complexity in a nuclear
aircraft carrier emanates from the potential
for unexpected sequences, complex tech-
nologies, and indirect information sources.
 Understanding Patient Safety and Medical Errors
Figure 3. Fit in High Reliability Organizations.
The organizational response to these factors
is the implementation of continuous training
and main direct information sources. Tight
coupling arises from time-dependent pro-
cesses, invariant sequence of operations, and
little slack, and the organization meets these
contingencies through redundancy and hier-
archical differentiation. Redundancy can take
many forms. Backup computers do the same
thing that online computers do (duplication),
and tasks are broken so that one person
may do tasks 1, 2, and 3, another person
does 2, 4, and 5, and another person does 1,
4, and 6 (overlap). Redundancy lessens the
negative effects of tight coupling by dealing
with numerous simultaneous outcomes and
decomposing the time frames. When things
are done quickly, the many pairs of eyes
available as watchdogs are a substitute to
unavailable time.13 In hierarchy, people have
specific roles within the invariant sequence
of behavior and are organized in a step-by-
step way to reach goals, such that everyone
knows who is ultimately responsible for
what.
Thompson14 defined technology as the
work performed by an organization. It com-
bines physical with intellectual processes to
transform material inputs into outputs. It
includes equipment, machines, and instru-
ments, in addition to skills and knowledge.
Technology has 3 main dimensions: uncer-
tainty, complexity, and interdependence.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
297
Complexity is the number of different ele-
ments that must be dealt with simultaneously
by the organization and is similar to Perrow’s
notion of complexity (thus, we will not
consider it separately). Uncertainty (or unpre-
dictability) is the variability of the elements
upon which the work is performed. Interde-
pendence is the degree to which elements are
interrelated to the extent that change in the
state of one affects the state of other. Inter-
dependence is similar to Perrow’s notion of
tight coupling, but we will consider it sepa-
rately because Thompson identifies 3 types
of interdependence: pooled, sequential, and
reciprocal interdependence.14 Thompson ar-
gues that as technical uncertainty increases,
formalization decreases, and flexibility and
decentralization increase. Moreover, as tech-
nical interdependence increases, coordination
increases through hierarchy, departmentaliza-
tion, rules and programs, and schedules.
Applying these concepts and relations to our
HRO, the nuclear aircraft carrier, a high level
of uncertainty and interdependence is ob-
served. Aboard ships, there is high environ-
mental uncertainty because of the nature of
war itself and because of changes in com-
mand, orders, and weather. High interdepen-
dence exists within the ship’s activities, with
no single unit being able to do its job without
input from many others. More specifically,
pooled interdependence occurs due to the
fact units make unique contributions to the
298 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
whole and are supported by it, sequential
interdependence arises from the fact flight
deck team members are specialists and each
set of them do their job in turn, whereas
reciprocal interdependence emanates from
officers bargaining through the specifics of a
flight plan depending on training and mission
ends.13 In HROs, interdependence is managed
though extreme hierarchy, whereas environ-
mental uncertainty is managed through de-
centralization. But how do these 2 conflicting
structures coexist in HROs? The paradox
becomes clear when we understand the
ability of HROs to reconfigure themselves
according to circumstances. Under routine
circumstances, they are controlled in the
conventional hierarchical manner. However,
under high-emergency situations, there is
tendency toward high decentralization: con-
trol shifts to the expert on the spot.5 Decision
making is pushed to the lowest possible level.
Even the lowest ranking officer can abort
landings on carriers. When they discover a
problem, individuals own the problem until
they solve it or until someone who can solve
it takes responsibility for it. The pyramid is
inverted with focus on low-level decision
making.13 Then once the crisis has passed, the
organization reverts seamlessly to the routine
control mode of hierarchy. Paradoxically, this
flexibility in shifting between decentralization
and hierarchy arises from a military tradition.
In military organizations, goals are defined in
an unambiguous way, and all participants
clearly understand and share aspirations so
that these bursts of semiautonomous activity
are successful. Thus, HROs encourage and
expect a variability of human action while, at
the same time, working hard to maintain a
consistent mindset of intelligent wariness.5
We have, thus far, described how HROs
manage to maintain fit between their context
and structure, thus operating at a low or zero
error rate. How is the situation like in health
care organizations? Although accidents in
health care affect only 1 patient at a time,
health care is undoubtedly a system of
complex interactions and tight coupling
and, thus, a system vulnerable to normal
accidents, as supported by the IOM’s report.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The complexity of the system confuses the
observers, whereas the tight coupling allows
things to unravel too quickly and thus
prevents errors from being intercepted. Espe-
cially in EDs, operating rooms, and intensive
care units, delivery of care occurs within a
complex and tightly coupled system.16
There are many sources of complexity,
uncertainty, and interdependence in health
care. First, human beings do not design or
build human bodies, nor do clinicians get
an ‘‘instruction manual’’ with every patient.
Relative to what we understand regarding
airplanes or nuclear reactors, the human
body is a ‘‘black box’’ whose functions are
still poorly understood. Second, unimagined
interactions result from the proliferation
of diagnostic and therapeutic technologies
used simultaneously, especially in EDs, oper-
ating rooms, and intensive care units. Third,
by their nature, health care organizations
are very complex, with multiple individuals,
teams, departments, and technologies brought
together to care for patients. Moreover, some
of the complexity and uncertainty also arises
from environmental pressures. Safety is not a
priority in health care organizations because
managed care, although slowing the growth in
costs, have resulted in the fact that cost con-
tainment is coming at the price of reducing
care and jeopardizing safety. Doctors and
nurses are subject to real pressures to maintain
production at all cost. Moreover, managed care
organizations use incentives to encourage
physicians to reduce expensive tests and
treatments, which might be at odds with
patient safety.5 Other indirect effect of these
pressures is that processes and strategies
implemented in HROs such as redundancy
and extensive training are not an option in
health care’s cost-containment atmosphere.
Thus far, we have shown that health care
faces the same contingencies that most
HROs face. We have already described
how HROs respond to these contingencies
through redundancy, training, hierarchy, and
decentralization. Health care organizations,
in contrast, have developed organizational
structures that are quite different from
these other high-hazard industries.12 Although
 Understanding Patient Safety and Medical Errors
hierarchical differentiation is highly present,
there is no attempt for decentralization. In
most settings, individual physicians are the
only ones to decide what care is rendered and
how it will be accomplished. Even under
conditions of high emergency, no delegation
of authority is allowed. The physician is treated
as the individual who can act alone to solve
medical problems by using his specialized
knowledge and skills to heroically save the
patients’ life. As described before, the intensive
training of personnel and intensive critique of
performance during operations and training
are practices widely adopted by HROs. Per-
sonnel who cannot measure up are quickly
identified, retrained, or replaced. In most
settings in health care, no extensive training
is in place after the initial training period
is completed. Physicians and nurses are ex-
pected to obtain their own ‘‘continuing edu-
cation’’ of their own choice, at their own
time, and at their own expense. Other differ-
ences that exist between health care and HROs
are that health care organizations impose very
weak control on the safety behavior of their
operations and that there is very little regula-
tion concerning the details of patient care
activities. Although high intensity of opera-
tions is 1 main characteristic of HROs, many
highly specialized procedures in health care
have proliferated to low-volume settings.
In brief, our discussion has suggested that
health care organizations, in general, operate
under a misfit between contingencies and
structures. This misfit is mainly due to lack of
flexibility, cost containment, and lack of
regulations, thus explaining the high level
of errors committed in these organizations.
Our general proposition is as follows:
Proposition 1: Lack of fit between context
and structure results in high error rates in
health care organizations.
Under this proposition, we suggest 2
specific subpropositions:
 Proposition 1a: Flexibility is a key
factor that can allow health care
organizations to adjust their structure
to the various situational demands.
 Proposition 1b: Redundancy, training,
hierarchical differentiation, and decen-
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
299
tralization are structures that must be
in place in health care organizations to
achieve high reliability.
ORGANIZATIONAL CULTURE
The concept of organizational culture
helps us understand the mysterious and
seemingly irrational things that happen in
organizations. Organizations develop cul-
tures that affect in many ways how the
members feel, think, and act. It is suggested
that the only thing of real importance that
leaders do is to create and manage culture.
Culture is a deep phenomenon that is
complex and difficult to understand. It is a
learned product of group experience. Thus,
culture can be learned, but most importantly,
it can be changed.
According to Schein (1985), culture is de-
fined as a ‘‘pattern of basic assumptions—
invented, discovered or developed by a given
group as it learns to cope with its problems
of external adaptation and internal integra-
tion- that has worked well enough to be
considered valid, and therefore to be taught
to new members as the correct way to
perceive, think, and feel in relation to these
problems.’’ Three levels of culture are
identified: (1) basic assumptions, which are
nonconfrontable, nondebatable, and uncon-
scious realities that constitute the essence of
culture; (2) values, which are the day-to-day
principles that guide behavior; and (3) arti-
facts, which are the constructed physical and
social events that are the observable mani-
festations of assumptions and values.17 These
levels of culture are schematized in figure 4.
In relation to safety, there are, in general, 2
types of organizational culture: culture of
blame and culture of safety. The culture of
blame is highly influenced by the ‘‘person
approach’’ to dealing with medical errors.
The person approach is based on the
premise that ‘‘bad things happen to bad
people’’ and thus focuses on the unsafe acts
of people at the ‘‘sharp end.’’ It advocates
that unsafe acts are a result of aberrant
mental processes, and it is concerned with
300 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
Figure 4. Levels of organizational culture. Adopted and modified from Knoke.17
making individuals less fallible by the ap-
plication of countermeasures such as pro-
cedures, disciplinary measures, threat of
litigation, naming, blaming, and shaming.5
It is important to recognize that blaming
the fallible individual at the sharp end, that
is, surgeons, physicians, anesthesiologists,
nurses, and pharmacists who are in direct
contact with vulnerable parts of the system,
is universal, natural, emotionally satisfying,
and legally convenient. Blaming individuals is
highly convenient for everyone. For lawyers,
it is easier to chase individual errors rather
than collective ones. For the victims and
their relatives, finding identifiable people is a
more satisfactory target for anger and grief
than some faceless organization.6 The need
to assign blame is so strong in us because
of mainly 3 powerful psychological forces
working in us:
1. Fundamental attribution error: when we
observe someone acting in an odd or
unsatisfactory fashion, we are inclined
to attribute the behavior to some
dispositional feature of the individual
rather than some situational aspects that
forced him/her to do what he/she did.
2. Illusion of free will: we place a large
value on personal autonomy, so that
when someone commits an error, we
are inclined to think that he/she chose a
deliberately wrong, error-prone course
of action.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3. Similarity bias: we tend to match the
like with the like, so that when huge
horrific errors are made, it seems natural
to suppose some equally monstrous act
of irresponsibility or incompetence as
the primary cause. The truth is, in fact,
that the causes are often relatively banal
factors that are hardly significant in
themselves but that are devastating
when combined.6
The person approach isolates errors from
their system context and thus has only limited
effectiveness. It has little or no remedial value
because blame focuses our attention on the
last or probably the least preventable link in
the chain of error. It also leads to ineffective
countermeasures such as disciplinary action,
exhortations to be more careful, retraining,
and writing new procedures. These measures
fail to improve outcomes, especially when
they are applied to an already well-qualified
and highly motivated workforce such as
health care professionals.
The culture of safety, in contrast, is in-
fluenced by the system approach to dealing
with errors described earlier. It is based on
the fact that humans are fallible and that
errors are to be expected, even in the best
organizations. It suggests that ‘‘we cannot
change human nature but we can change the
conditions under which humans work.’’5 A
safety culture is a culture where all workers
accept responsibility for the safety of patients.
 Understanding Patient Safety and Medical Errors
It is facilitated by an organization that pri-
oritizes safety above financial and operational
goals; encourages and rewards identification,
communication, and resolution of safety is-
sues; and provides a venue for organizational
learning from accidents and appropriate re-
sources, structure, and accountability to
maintain effective safety systems. Applying
Schein’s 3-level model to the understanding of
the culture of blame and the culture of safety
in health care is of great value. Table 1
schematizes this application.
Although national culture is important, it
is the organizational culture that ultimately
shapes the perception of safety by organiza-
tional members, the relative importance
placed on safety and members’ activities re-
garding safety. There are so many subcultures
within the same organizations. An integrated
organizational culture in which subcultures
are united by common values and beliefs is
preferred to a discordant culture.
An integrated organizational culture is
characterized by (1) cooperation, (2) strong
corporate identity, (3) a positive organiza-
Table 1. Applying Schein’s model to the culture of blame and the culture of safety
Culture of blame
Artifacts Patient safety reports are used for
disciplinary action.
No regular review of patient safety
information
Underreporting of errors
Error reporting process is too long
and too complicated.
Confidentiality of reporting is unclear
Error information that is reported is
not used for improvement.
Weak safety leadership
Values Blaming individuals for errors
Errors are seen as person/human errors.
Fear of being sued
Errors not seen as opportunity for
learning
Medical errors is not a severe enough
problem.
Beliefs and Cost containment comes first
assumptions Fundamental attribution error
Illusion of free will
Similarity bias
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
301
tional climate, and (4) high employee mo-
rale. These factors when combined create a
positive impact on service and overall safety.
In their effort in changing the organizational
culture from a culture of safety to a culture of
blame, organizational leaders must first aim
at unifying and strengthening the organiza-
tional culture, and then aim at introducing
safety as a shared value that will provide
the underlying logic directing all mem-
bers’ behavior. As suggested by Meritt and
Helmreich,7 ‘‘a safety culture is more than a
group of individuals enacting a set of safety
guidelines—it is a group of individuals
guided in their behavior by their joint belief
in the importance of safety, and their shared
understanding that every member willingly
upholds the group’s safety norms and will
support other members to that common
end.’’ To achieve that, leaders should articu-
late the desired values and reinforce the
appropriate norms. Although it may be pos-
sible to make people change their behavior,
it is much harder to direct people to change
their values and beliefs. If the underlying
Culture of safety
Patient safety reports are used for quality and
performance improvement.
Frequent review of patient safety information
Errors and near misses are adequately reported.
Simple, effective process for reporting errors
Protection of confidentiality of reporting
Error information that is reported is used to
prevent future errors
Strong safety leadership
Focus on ‘‘what happened’’ rather than
‘‘who did it’’
Errors are seen as system failures
No fear of being sued
Errors seen as opportunity to learn and
improve
Medical errors is a severe problem
Safety comes first.
Errors are due to situational factors
No illusion of free will
Causes of errors are relatively banal in
themselves
302 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
values and beliefs are not in place to guide
behavior, behavior change is only short lived.
A sad truth about culture change is that
change is slow. Creating a safety culture is a
multiyear process that takes tremendous
efforts. Having said that, it is possible to
pinpoint to some strategies that can lead
cultural change:
1. Leaders should act as role models and
be the active promoters of the safety
culture and its desired outcomes.
2. New members of the organization
should be socialized through a system
that allows a senior person to explain
the safety culture to a new comer. By
explaining why something is done the
way it is, the underlying or implicit safety
structure of the organization is revealed.
3. Organizations should be proactive
when dealing with safety rather than
reacting in a band-aid fashion. Periodic
preventive safety audits should be
implemented to identify weaknesses
and latent failures in the system before
they lead to active failures.
4. Organizations should encourage and
reward vigilance and inquire from all
its members.
5. An integrated approach focusing on
system-wide investigation and remedia-
tion should replace the philosophy of
blame and punishment.
6. Organizations should continually com-
municate results and celebrate suc-
cesses because publicizing results is
very important to sustaining efforts
and keeping everyone motivated.7
Based on the above discussion, we suggest
the following proposition:
Proposition 2: Health care organizations
must change their assumptions, beliefs,
values, and artifacts in order to change
their culture from a culture of blame to a
culture of safety and thus reduce medical
errors.
ORGANIZATIONAL LEARNING
In general, organizational learning is a
system of actions, actors, symbols, and the
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
process that enables organizations to trans-
form information into valued knowledge
which in turn increases its long-run adaptive
capacity.17 It is the process of both individual
and collective learning both within and
between organizations.18 Change in routines
is one major aspect of organizational learn-
ing. Routines are forms, rules, procedures,
conventions, and strategies around which
and through which organizations are con-
structed and operated.17
The application of an organizational learn-
ing perspective to explaining error rates have
been used before by Weick and Roberts.19
They argued that organizational learning
consists of interrelating actions of individuals
that are their ‘‘heedful interrelation’’ which
results in a collective mind. Heedful interre-
lation occurs through contribution, repre-
sentation, and subordination. They suggest
that organizational learning leads to a de-
crease in organizational errors.
The collective knowledge and wisdom of
an organization is greater than that of its
individual members if the organization is
designed in a way that allows it to benefit
from experience. Unless very particular care
is taken to enhance it, corporate memory is
very volatile.7 Organizations must continu-
ally measure their performance and learn
from mistakes. Organizational learning occurs
when an organization changes its behavior
as a result of past errors in a way that is
reflected in the behavior of its members. For
this to become possible, organizations must
acknowledge errors through establishing
reporting systems. Errors should be seen as
signals for a needed change in practice, and
reports must be taken as information based
on which the organization can make con-
structive change.7
High Reliability Organizations are ‘‘preoc-
cupied with failure,’’ as they attempt to
incorporate experience from accidents and
incidents analysis with anticipatory planning
and simulation. For example, commercial
aviation has implemented high profile, high-
capable independent organization for the
investigation of the probable causes of ac-
cidents. It has also implemented several
 Understanding Patient Safety and Medical Errors
programs of reporting and analysis of inci-
dents or ‘‘near-misses,’’ and it has emerging
programs to analyze data from flights not
involving an incident or an accident. Histori-
cally, in health care, the systems of investi-
gation and reporting of adverse events are
relatively weak. Only a handful of events are
officially reported through the quality man-
agement system of a given hospital.12 Most
health care organizations are extremely rigid
and unable to learn from past experience.
After an error, very few are learned from an
organizational viewpoint because, in most
cases, records are not kept, nor are they used
to determine how to change the system.7
A recent event that might accelerate
organizational learning is the policy by Joint
Commission on Accreditation of Healthcare
Organization ( JCAHO) requiring accredited
organizations to conduct root-cause analysis
of significant adverse events called ‘‘sentinel
events.’’ Organizations report severe sentinel
events to JCAHO, which will review the
analysis and response of the organization and
judge it as either acceptable or nonaccept-
able. In the latter case, JCAHO can place the
organization on ‘‘accreditation watch’’ sta-
tus. Sentinel events are received by JCAHO,
and JCAHO published Sentinel Events Alerts
summarizing the lessons learned and the
recommendations.12 This is clearly an exam-
ple of learning at the population level.
Moreover, various parts in health care have
been interested in establishing voluntary
event reporting and analysis systems that
are similar to Aviation Safety Reporting
System. This system is characterized by the
collection of voluntary reports from frontline
workers, confidentiality of reporting, ana-
lyses of the reports by domain experts,
issuing of alert messages to specific organi-
zations, and frequent feedback to the avia-
tion community on reports and analyses.
Complications that might face the applica-
tion of this system in health care is difficulty
in distinguishing incidents from accidents
and the liability issues of handling reports of
events that could be subject to litigation.
However, despite good reporting and
analysis of incidents and accidents, organiza-
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
303
tional learning does not always take place. As
stated by Rijpma:12 Initially learning may
progress rapidly, as the easy lessons are
learned. But when accidents and near ac-
cidents become more complex, reconstruc-
tion of what exactly happened becomes
more difficult [concept attributed to Paul
Schulman]. The causes of accidents and near
accidents are often many, so there are many
‘‘hooks’’ to hang lessons on and many hooks
not to hang lessons on. Diverging interpreta-
tions can lead to conflicting perspectives on
how to improve activities. These conflicts
may result in one-sided solutions, or even
deadlocks. Thus, learning which starts of as a
difficult cognitive process becomes more of a
political process as time goes by. Compre-
hensive learning, leading to a breakthrough
in reliability, is more often a process of
learning to build coalitions than a process of
learning to understand events.
Another factor that can hamper organiza-
tional learning is the culture of blame, as will
be described in detail in the following section.
Our application of organizational learning to
the understanding of error reporting in health
care results in the following proposition:
Proposition 3: Organizational learning,
which occurs through reporting, analyzing,
and acting on error information, can result in
reduced errors in health care organizations.
DISCUSSION AND CONCLUSION
Contingency theory, organizational cul-
ture, and organizational learning each offered
separate insights on the issue of patient
safety and medical errors. In this section, we
explain how these perspectives can be
complementary, thus allowing us to see the
big picture. The first link that we will make is
between contingency theory and organiza-
tional culture. As described in the third
section, health care organizations must be
both centralized and decentralized if they are
to cope with contextual contingencies and
reduce their error rates. However, a system
in which both centralization and decentrali-
zation occur is difficult to be designed. This
is where culture plays an important role. As
304 THE HEALTH CARE MANAGER/OCTOBER–DECEMBER 2006
stated by Weick, ‘‘before you can centralize
you have first to decentralize so that people
are socialized to use similar decision premises
and assumptions so that when they operate
their own units, those decentralized options
are equivalent and coordinated.’’20 Culture
can impose order and serve as a substitute for
centralization. Culture creates a homoge-
neous set of assumptions and decision pre-
mises, which when invoked on a local and
decentralized level, they allow coordination
and centralization to be preserved. More
importantly, compliance in this case occurs
without the need for surveillance.
Another link is between organizational
culture and organizational learning. As sug-
gested before, organizational learning can be
hampered by cultures of blame that pervade
many health care organizations. Rather than
asking the questions about the root causes
of the errors, it is easier to find culprits
for errors and to point fingers at a single
individual.
Especially in organizations with strong
competition for resources and power, orga-
nizational culture is a source of blame and a
block to effective learning. Units or de-
partments associated with an accident at-
tempt to shift the blame to others, whereas
hospitals in general have strong incentives
to hide errors because of fear of litigation.
Although in hospitals, cases of adverse
occurrences are discussed at monthly mor-
bidity and mortality conferences, ground
rounds, and peer review, these activities
‘‘all share the same shortcomings: a lack of
human factors and thinking about systems, a
narrow focus on individual performance to
the exclusion of contributory team and larger
social issues, hindsight bias, a tendency to
search for errors as opposed to the myriad
causes of error induction, and a lack of mul-
tidisciplinary integration into an organiza-
tional wide safety culture.’’10
Another connection can also be made
between culture and learning. In high-hazard
industries such as health care, a major
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
learning strategy, trial and error, is not
possible because errors cannot be contained.
However, reliable performance is difficult
when trial and error are precluded. Thus,
substitutes for trial and error should be
developed in the system. An important aspect
of these substitutes is an organizational
culture of safety that values storytelling.
As described by Weick,14 ‘‘a system that
values stories and storytelling is potentially
more reliable because people know more
about their system, know more of the po-
tential errors that might occur, and they are
more confident that they can handle those
errors that do occur because they know
that other people have already handled
similar errors.’’
In brief, high reliability organizations are a
prime example of the system approach. They
design their structure in a flexible way that
allows proper fit with the contextual contin-
gencies; they rely on a strong culture of
safety that manifests itself as an organization
learning from its mistakes in order to im-
prove. Thus, our last proposition is as follows:
Proposition 4: Adequate fit between
structures and processes, permitted through
a safety culture and enhanced through
learning, is an important path to be
adopted by health care organizations to
reduce medical errors.
In conclusion, we have adopted a 3-angle
approach to examine errors in health care
organizations and suggested 4 general propo-
sitions based on research and findings from
other fields and industries. The propositions
can be broken down into further subpropo-
sitions that can serve as testable hypotheses
in future research. The field of medical errors
in specific and health care, in general, can
benefit substantially from the assessment of
the relationships that we described. The
health care industry needs to change its
preoccupation with individual factors and
start examining organizational factors if it is
to reduce error, improve safety, and cross
the quality chasm.
 Understanding Patient Safety and Medical Errors
REFERENCES
1. Institute of Medicine. To Err Is Human: Building
a Safer Health System. Washington, DC: National
Academy Press; 2000.
2. Wachter RM. The End of the Beginning. Patient
Safety Five Years After ‘‘To Err is Human.’’ Health
Aff. Web Exclus. November 30, 2004;W4:534-545.
3. Robeznieks A. Are Patients Safe Now? Am Med
News. October 13, 2003:12-13.
4. Longo DR, Hewett JE, Ge B, Shcubert S. The long
road to patient safety: a status report on patient
safety systems. JAMA. 2005;294:2858-2865.
5. Reason J. Human error: models and management.
Br Med J. 2000;320:768-770.
6. Reason J. Foreword. In: Bogner MS, ed. Human
Error in Medicine. Hillside, NJ: Lawrence Erlbaum
Association; 1994.
7. Merritt AC, Helmreich RL. Creating and sustaining a
safety Culture. CRM Advocate. 1996:18-12.
8. Galbrith J. Designing Complex Organizations. Read-
ing, MA: Addison-Wesley; 1973.
9. Pfeifer J. Organizations and Organization Theory.
Cambridge, MA: Ballinger; 1982.
10. Donaldson L. The normal science of structural con-
tingency theory. In: Clegg, Hardy, Nord, eds. Hand-
book of Organization Studies. London: Sage; 1996.
11. Argote L. Input uncertainty and organizational coor-
dination in hospital emergency units. ASQ. 1982;
274:20-434.
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
305
12. Gaba DM. Structural and organizational issues in
patient safety: a comparison of healthcare to other
high-hazard industries. Calif Manage Rev. 2000;
43(1):83-102.
13. Roberts KH. Some characteristics of one type of
high reliability organization. Organ Sci. 1990;1(2):
160-176.
14. Scott WR. ‘‘The Subject Is Organizations.’’ Organi-
zations: Rational, Natural and Open Systems. 1998
Englewood Cliffs, NJ: Prentice Hall; Ch 1.
15. Schein E. Defining organizational culture. In:
Shafritz JM, Ott JS, eds. Classics of Organization
Theory. Orlando, FL: Harcorut Brace and Company;
1996.
16. Knoke D. Changing Organizations: Business Net-
works in the New Political Economy. Chapter 2:
Complementary Theories of Change. Boulder, CO:
Westview Press; 2001.
17. Prange C. Organizational learning: desperately seek-
ing theory? In: Easterby-Smith M, Araujo L, Burgoyne
J, eds. Organizational Learning and the Learning
Organizations: Development in Theory and Prac-
tice. Thousand Oaks: Sage Publications; 1999.
18. Weick KE, Roberts KH. Collective mind in organi-
zations: heedful interrelating on flight decks. ASQ.
1993;38:357-381.
19. Weick KE. Organizational culture as a source of high
reliability. Calif Manage Rev. 1987;29:112-127.