Amy Edmondson

In 1991, a first-year PhD student named Amy Edmondson began visiting hospital wards, intending to show that good teamwork and good medicine went hand in hand. But the data kept saying she was wrong.

Edmondson was studying organizational behavior at Harvard. A professor had asked her to help with a study of medical mistakes, and so Edmondson, on the prowl for a dissertation topic, started visiting recovery rooms, talking to nurses, and paging through error reports from two Boston hospitals. In one cardiac ward, she discovered that a nurse had accidentally given a patient an IV of lidocaine, an anesthetic, rather than heparin, a blood thinner. In an orthopedic ward, a patient was given amphetamines rather than aspirin. “You would be shocked at how many mistakes occur every day,” Edmondson told me. “Not because of incompetence, but because hospitals are really complicated places and there’s usually a large team-as many as two dozen nurses and techs and doctors-who might be involved in each patient’s care. That’s a lot of opportunities for something to slip through the cracks.”

Some parts of the hospitals Edmondson visited seemed more accident prone than others. The orthopedic ward, for instance, reported an average of one error every three weeks; the cardiac ward, on the other hand, reported a mistake almost every other day. Edmondson also found that the various departments had very different cultures.
In the cardiac ward nurses were chatty and informal; they gossiped in the hallways and had pictures of their kids on the walls. In orthopedics, people were more sedate. Nurse managers wore business suits rather than scrubs and asked everyone to keep the public areas free of personal items and clutter. Perhaps, Edmondson thought, she could study the various teams’ cultures and see if they correlated with error rates.
She and a colleague created a survey to measure team cohesion on various wards. She asked nurses to describe how frequently their team leader set clear goals and whether teammates discussed conflicts openly or avoided tense conversations. She measured the satisfaction, happiness, and self-motivation of different groups and hired a research assistant to observe the wards for two months.
“I figured it would be pretty straightforward,” Edmondson told me. “The units with the strongest sense of teamwork would have the lowest error rates.” Except, when she tabulated her data, Edmondson found exactly the opposite. The wards with the strongest team cohesion had far more errors. She checked the data again. It didn’t make any sense. Why would strong teams make more mistakes?
Confused, Edmondson decided to look at these nurses’ responses, question by question, alongside the error rates to see if any explanations emerged. Edmondson had included one survey question that inquired specifically about the personal risks associated with making errors. She asked people to agree or disagree with the statement: “If you make a mistake in this unit, it is held against you.” Once she compared the data from that question with error incidence, she realized what was going on. It wasn’t that wards with strong teams were making more mistakes. Rather, it was that nurses who belonged to strong teams felt more comfortable reporting their mistakes. The data indicated that one particular norm-whether people were punished for missteps-influenced if they were honest after they screwed up.

What particularly surprised her, however, was how complicated things got the closer she looked: it wasn’t simply that strong teams encouraged open communication and weak teams discouraged it. In fact, while some strong teams emboldened people to admit their mistakes, other, equally strong teams made it hard for nurses to speak up. What made the difference wasn’t team cohesion-rather, it was the culture each team established. In one ward with a strong team, for instance, nurses were overseen by “a hands-on manager who actively invites questions and concerns. “There is an unspoken rule here to help each other and check each other,” a nurse told Edmondson’s assistant. “People feel more willing to admit to errors here, because the nurse manager goes to bat for you.”

In another ward with a team that, at first glance, seemed equally strong, a nurse said that when she admitted hurting a patient while drawing blood, the nurse manager “made her feel like she was on trial.” Another said doctors “bite your head off if you make a mistake.”

It wasn’t the strength of the team that determined how many errors were reported-rather, it was one specific norm.

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