Organizational errors: Directions for future research

The goal of this chapter is to promote research about organizational errors—i.e., the actions of multiple organizational participants that deviate from organizationally specified rules and can potentially result in adverse organizational outcomes. To that end, we advance the premise that organizational errors merit study in their own right as an organizational-level phenomenon of growing theoretical and managerial significance. We delineate organizational errors as a construct that is distinct from but related to individual-level errors, and draw attention to its multi-level antecedents, mediating processes, and outcomes. We also discuss error management processes such as prevention, resilience, and learning, and call for research to expand our currently limited understanding of how these processes unfold over time, i.e., before, during, and after the occurrence of organizational errors. Further, in the light of a recurring critique of prior error-related organizational studies as being narrowly context-bound and therefore of limited interest to organizational researchers in general, we elaborate on the critical need for future research to explicitly take into account the role of contextual features. We conclude with a discussion of key themes, unresolved issues, and promising research directions.

[1]  A. Edmondson Learning from failure in health care: frequent opportunities, pervasive barriers , 2004, Quality and Safety in Health Care.

[2]  Steven Meisel,et al.  “Ain't Misbehavin”: Workplace deviance as organizational resistance , 2008 .

[3]  K. Sutcliffe,et al.  Controlling Decision-Making Practice in Organizations , 2001 .

[4]  Nassim Nicholas Taleb,et al.  The Black Swan: The Impact of the Highly Improbable , 2007 .

[5]  Heather Shearer,et al.  The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries , 2009 .

[6]  Sidney Dekker,et al.  Ten Questions About Human Error : A New View of Human Factors and System Safety , 2004 .

[7]  D. M. Clarke Managing the Unexpected: Resilient Performance in an Age of Uncertainty (2nd edn) Karl E Weick and Kathleen M Sutcliffe (2007) Wiley & Sons, San Francisco; ISBN 978-0-7879-9649-9; HC; 194 pages; USD 27.05 , 2008, Journal of Management & Organization.

[8]  R. Westrum Cultures with Requisite Imagination , 1993 .

[9]  J. Hackman Learning more by crossing levels: evidence from airplanes, hospitals, and orchestras , 2003 .

[10]  M. O'hare,et al.  Searching for Safety , 1990 .

[11]  C. Hardy Organizations: Rational, Natural and Open Systems , 1983 .

[12]  S. Kozlowski,et al.  Multilevel Theory, Research, a n d M e t h o d s i n Organizations Foundations, Extensions, and New Directions , 2022 .

[13]  Deborah G. . Ancona,et al.  Time: A New Research Lens , 2001 .

[14]  Eitan Naveh,et al.  Safety Climate in Health Care Organizations: A Multidimensional Approach , 2005 .

[15]  David Woods Medical Error: What Do We Know? What Do We Do? , 2002, BMJ : British Medical Journal.

[16]  Scott D. Sagan,et al.  Hostages of Each Other: The Transformation of Nuclear Safety Since Three Mile Island. , 1995 .

[17]  P. Goodman,et al.  Latent errors and adverse organizational consequences: a conceptualization , 2003 .

[18]  Frank Dobbin,et al.  Review of James G. March, Martin Schulz, and Xueguang Zhou, The Dynamics of Rules: Change in Written Organizational Codes , 2000 .

[19]  Preventing errors relating to commonly used anticoagulants. , 2008, Sentinel event alert.

[20]  Rangaraj Ramanujam,et al.  THe Effects of Discontinuous Change on Latent Errors in Organizations: The Moderating Role of Risk , 2003 .

[21]  M. Frese,et al.  Organizational error management culture and its impact on performance: a two-study replication. , 2005, The Journal of applied psychology.

[22]  A. Edmondson,et al.  The Importance of Work Context in Organizational Learning from Error , 2011 .

[23]  Arwen Mohun,et al.  The Limits of Safety: Organizations, Accidents, and Nuclear Weapons , 1993 .

[24]  Harvey M. Sapolsky,et al.  The Limits of Safety: Organizations, Accidents, and Nuclear Weapons , 1995 .

[25]  Denise M. Rousseau,et al.  The challenges are organizational not just clinical , 2006 .

[26]  K. Roberts New Challenges to Understanding Organizations , 1993 .

[27]  D. Vaughan THE DARK SIDE OF ORGANIZATIONS: Mistake, Misconduct, and Disaster , 1999 .

[28]  L. Clarke Mission Improbable: Using Fantasy Documents to Tame Disaster , 1999 .

[29]  Karl E. Weick,et al.  Managing the unexpected: Assuring high performance in an age of complexity. , 2001 .

[30]  W. Skipper,et al.  Shouldering Risks: The Culture of Control in the Nuclear Power Industry , 2006 .

[31]  K. Weick,et al.  Collective mind in organizations: Heedful interrelating on flight decks. , 1993 .

[32]  G. Pisano,et al.  Disrupted Routines: Team Learning and New Technology Implementation in Hospitals , 2001 .

[33]  A. Edmondson Psychological Safety and Learning Behavior in Work Teams , 1999 .

[34]  Marvin C. Alkin,et al.  What Have We Learned? , 2019, Stumbling Blocks Against Unification.

[35]  B. Fischhoff,et al.  AN EARLY HISTORY OF HINDSIGHT RESEARCH , 2007 .

[36]  Jens Rasmussen,et al.  Risk management in a dynamic society: a modelling problem , 1997 .

[37]  Felix Redmill,et al.  Human Factors in Safety-Critical Systems , 1997 .

[38]  David A. Hofmann,et al.  Errors in Organizations , 2011 .

[39]  M. Frese,et al.  Effectiveness of error management training: a meta-analysis. , 2008, The Journal of applied psychology.

[40]  P. Adler Building better bureaucracies , 1999 .

[41]  C. Perin Organization at the Limit: Lessons from the Columbia Disaster , 2006 .

[42]  David A. Hofmann,et al.  Errors, error taxonomies, error prevention, and error management , 2011 .

[43]  René Amalberti,et al.  Errors and Failures: Towards a New Safety Paradigm , 2007 .

[44]  Karlene H. Roberts,et al.  The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea , 1987 .

[45]  Susan Dentzer,et al.  Still crossing the quality chasm--or suspended over it? , 2011, Health affairs.

[46]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[47]  C. Landrigan,et al.  Temporal trends in rates of patient harm resulting from medical care. , 2010, The New England journal of medicine.

[48]  Jens Rasmussen,et al.  Cognitive Control and Human Error Mechanisms , 1987 .

[49]  Marlys K. Christianson,et al.  A sensemaking lens on reliability , 2006 .

[50]  James G. March,et al.  How Decisions Happen in Organizations , 1991, Hum. Comput. Interact..

[51]  Timothy J. Vogus,et al.  The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units , 2007, Medical care.

[52]  E. Thomas,et al.  Classifying and interpreting threats to patient safety in hospitals: insights from aviation , 2006 .

[53]  R. Lamb,et al.  Open disclosure: the only approach to medical error , 2004, Quality and Safety in Health Care.

[54]  P. Slovic Perception of risk. , 1987, Science.

[55]  J. Rudolph,et al.  Learning from experience in high-hazard organizations , 2002 .

[56]  Y. Fried,et al.  Location, location, location: contextualizing organizational research* , 2001 .

[57]  P. Schulman,et al.  General attributes of safe organisations , 2004, Quality and Safety in Health Care.

[58]  A. Edmondson Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error , 1996 .

[59]  Barbara A. Spencer,et al.  MODELS OF ORGANIZATION AND TOTAL QUALITY MANAGEMENT: A COMPARISON AND CRITICAL EVALUATION , 1994 .

[60]  David W. Lehman,et al.  Selectivity in Organizational Rule Violations , 2009 .

[61]  Chen Shao-mi,et al.  On Group- learning , 2005 .

[62]  Steven J. Spear,et al.  Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch up and Win , 2008 .

[63]  Peter J Pronovost,et al.  Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out , 2010 .

[64]  D. Hofmann,et al.  The Structure and Function of Collective Constructs: Implications for Multilevel Research and Theory Development , 1999 .

[65]  Kathleen M. Sutcliffe,et al.  Doing No Harm : Enabling , Enacting , and Elaborating a Culture of Safety in Health Care by , 2010 .

[66]  Gary Johns,et al.  The joint effects of personality and job scope on in-role performance, citizenship behaviors, and creativity , 2010 .

[67]  J. Dutton,et al.  Positive Organizational Scholarship , 2007 .

[68]  Arthur D. Shulman,et al.  Missing Organizational Linkages: Tools for Cross-Level Research , 2000 .

[69]  Diane Vaughan,et al.  The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA , 1996 .

[70]  V. David Hopkin,et al.  Verification and Validation of Complex Systems: Human Factors Issues , 1993 .

[71]  R. I. Sutton,et al.  Organizational behavior: linking individuals and groups to organizational contexts. , 1993, Annual review of psychology.

[72]  S. Kozlowski,et al.  A Typology of Virtual Teams , 2002 .

[73]  Scott Snook,et al.  Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq , 2002 .

[74]  Amy C. Edmondson,et al.  The Recovery Window: Organizational Learning Following Ambiguous Threats , 2004 .

[75]  B. Turner The Organizational and Interorganizational Development of Disasters , 1976 .

[76]  K. Sutcliffe,et al.  Overcoming dysfunctional momentum: Organizational safety as a social achievement , 2009 .

[77]  Michael R. Beauregard,et al.  The Basics of FMEA , 1996 .

[78]  D. Hofmann,et al.  An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. , 2006 .

[79]  Timothy J. Vogus,et al.  Organizing For Resilience , 2003 .

[80]  R E Miles,et al.  Organizational strategy, structure, and process. , 1978, Academy of management review. Academy of Management.

[81]  T. Snijders Statistical Models for Social Networks , 2011 .

[82]  Gary Klein,et al.  Sources of Power: How People Make Decisions , 2017 .

[83]  K. Weick The social psychology of organizing , 1969 .

[84]  S. Kozlowski,et al.  Multilevel Theory, Research, and Methods in Organizations: Foundations, Extensions, and New Directions , 2000 .

[85]  K. Roberts Some Characteristics of One Type of High Reliability Organization , 1990 .

[86]  Barry M. Staw,et al.  Threat-rigidity effects in organizational behavior: A multilevel analysis. , 1981 .

[87]  Peter Cappelli,et al.  Spanning the Union/Nonunion Boundary , 1989 .

[88]  Nancy G. Leveson,et al.  Applying systems thinking to analyze and learn from events , 2010 .

[89]  Karl E. Weick,et al.  Managing the unexpected: resilient performance in an age of uncertainty, second edition , 2007 .

[90]  A. Edmondson Speaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams , 2003 .

[91]  R. Matthews,et al.  Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out , 2011, The Journal of Nuclear Medicine.

[92]  Barack Obama,et al.  Executive Order 13543: National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling , 2010 .

[93]  J. A. Wise,et al.  Verification and Validation of Complex Systems: Human Factors Issues , 1993, NATO ASI Series.

[94]  Emery Roe,et al.  High Reliability Management: Operating on the Edge , 2008 .

[95]  K. Weick,et al.  Organizing for high reliability: Processes of collective mindfulness. , 1999 .

[96]  Zohar Dov,et al.  Safety Climate and Beyond: A Multi-Level Multi-Climate Framework , 2008 .

[97]  Claus Rerup,et al.  Attentional Triangulation: Learning from Unexpected Rare Crises , 2009, Organ. Sci..

[98]  Anita L. Tucker,et al.  Why Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change , 2003 .

[99]  Kathleen M. Sutcliffe,et al.  Mindfulness and the Quality of Organizational Attention , 2006, Organ. Sci..

[100]  N. Repenning,et al.  Disaster Dynamics: Understanding the Role of Quantity in Organizational Collapse , 2002 .

[101]  Karlene H. Roberts,et al.  The Incident Command System : High Reliability Organizing for Complex and Volatile Task , 2007 .

[102]  Eitan Naveh,et al.  Treatment Errors in Healthcare: A Safety Climate Approach , 2005, Manag. Sci..

[103]  J. March Exploration and exploitation in organizational learning , 1991, STUDI ORGANIZZATIVI.

[104]  Babette Fahlbruch,et al.  “The gift of failure: New approaches to analyzing and learning from events and near-misses.” Honoring the contributions of Bernhard Wilpert , 2010 .

[105]  D. Norman,et al.  New technology and human error , 1989 .