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

Tucker & Edmondson · 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.

Tucker, A.L. and Edmondson, A.C. (2003) 'Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change', California Management Review, 45(2), pp. 55–72.

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