Reviewing Organizational Failures: The Case of Medical Accidents

NYU professor Lucy MacPhail has earned a best paper award here at Academy of Management for her paper examining how an academic medical center conducts reviews of medical accidents. In healthcare, regulators dictate that certain types of errors must be subjected to a formal organizational review. MacPhail found that the hospital did indeed conduct systematic reviews in accordance with regulatory oversight. However, her research shows that the hospital did not review a number of incidents which had the potential to provide substantial learning opportunities. Why not? Those incidents did not fall under the regulatory rules. In other words, the focus on compliance may steer managers away from investigating failures which may yield key learning. I believe that similar experiences may exist in a number of other industries. MacPhail recommends that organizationals their own learning goals, independent of compliance concerns. Those learning goals should drive the selection of projects to review in a systematic manner.