# Why Hospitals Don't Learn from Failures: Organizational and Dynamics That Inhibit System Change

*Tucker · Safety & Error, Team Learning · California Management Review · 2003 · Open access*

Observational study of 26 nurses across nine hospitals, documenting how frontline workers routinely encountered operational failures — missing supplies, wrong information, broken equipment — and responded with first-order problem-solving (workarounds) rather than second-order learning (fixing the system). The structural inhibitors were time pressure, lack of psychological safety to escalate, and a management culture that rewarded individual heroics over system improvement. One of the most cited papers connecting PS to organisational learning in healthcare, and a direct empirical ancestor of PSIRF's shift from individual incident investigation to systemic learning.

- **This page:** https://explore.psychsafety.com/n/tucker-edmondson-2003/
- **View the source paper:** https://www.utsouthwestern.edu/employees/leadership-programs/leadership-foundations/why-hospitals-dont-learn.pdf
- **Interactive map:** https://explore.psychsafety.com/?mode=papers&node=tucker-edmondson-2003

## Connected concepts (19)

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- [Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units](https://explore.psychsafety.com/n/nembhard-tucker-2011.md) (paper)
- [Failing to Learn and Learning to Fail (Intelligently): How Great Organizations Put Failure to Work to Innovate and Improve](https://explore.psychsafety.com/n/cannon-edmondson-2005.md) (paper)
- [High-Quality Relationships, Psychological Safety, and Learning from Failures in Work Organizations](https://explore.psychsafety.com/n/carmeli-gittell-2009.md) (paper)
- [Human Error: Models and Management](https://explore.psychsafety.com/n/reason-2000.md) (paper)
- [Psychological Safety, Trust, and Learning in Organizations: A Group-level Lens](https://explore.psychsafety.com/n/edmondson-2003.md) (paper)
- [Resilience and Precarious Success](https://explore.psychsafety.com/n/patterson-wears-2015.md) (paper)
- [Blametropism](https://explore.psychsafety.com/n/blametropism.md)
- [Errors in Organizations: An Integrative Review via Level of Analysis, Temporal Dynamism, and Priority Lenses](https://explore.psychsafety.com/n/lei-naveh-novikov-2016.md) (paper)
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- [Just Culture](https://explore.psychsafety.com/n/just-culture.md)
- [Linking Leader Inclusiveness to Work Unit Performance: The Importance of Psychological Safety and Learning from Failures](https://explore.psychsafety.com/n/hirak-et-al-2012.md) (paper)
- [Making it Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams](https://explore.psychsafety.com/n/nembhard-edmondson-2006.md) (paper)
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- [Normal Accidents](https://explore.psychsafety.com/n/normal-accidents.md)
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- [The Limits of Psychological Safety: Nonlinear Relationships with Performance](https://explore.psychsafety.com/n/eldor-hodor-cappelli-2023.md) (paper)
- [WAI vs WAD](https://explore.psychsafety.com/n/psychological-safety-work-as-imagined-vs-work-as-done.md)