When Things Go Wrong: How Health Care Organizations Deal With Major Failures

Kieran Walshe; Stephen M. Shortell


Health Affairs. 2004;23(3) 

In This Article

Abstract and Introduction


Concern about patient safety, caused in part by high-profile major failures in which many patients have been harmed, is rising worldwide. This paper draws on examples of such failures from several countries to analyze how these events are dealt with and to identify lessons and recommendations for policy. Better systems are needed for reporting and investigating failures and for implementing the lessons learned. The culture of secrecy, professional protectionism, defensiveness, and deference to authority is central to such major failures, and preventing future failures depends on cultural as much as structural change in health care systems and organizations.


The past decade has brought a growing public realization in many countries that health care facilities are often dangerous places. Reports published in the United States, the United Kingdom, Australia, New Zealand, and Canada have focused public and policy attention on the safety of patients and have highlighted the alarmingly high incidence of errors and adverse events that lead to some kind of harmor injury.[1] Health care organizations and systems are starting to recognize and use ideas, models, and techniques from safety science, which were developed and have long been applied in other industrial and commercial settings where safety and reliability are critical concerns.[2]

The patient-safety movement has been driven in some countries by high-profile instances of major health care failure.[3] These events usually involve a breakdown in health care services or provision that does substantial harm to many patients. Such events are different from the tragic single instances of failure and harm to a patient that are sometimes widely reported in the media, such as the Boston Globe reporter who suffered a fatal medication error at the Dana-Farber Cancer Institute in 1994, or the more recent case of a mismatched heart-lung transplantation at Duke University Medical Center.[4] Here we are referring to catalogues of chronic, unremedied failure often stretching over months or years.

Perhaps the best-known recent example was the failure in pediatric cardiac surgery at the Bristol Royal Infirmary in England.[5] Between 1990 and 1995, despite repeated warnings about poor surgical quality outcomes, cardiac surgeons at the hospital continued to operate on newborns until the U.K. Department of Health forced them to stop. A subsequent public inquiry concluded that about thirty-five deaths had been avoidable.[6] Three doctors were disciplined by the General Medical Council, and two lost their licenses to practice medicine. The Bristol affair has been a powerful political lever for change in the National Health Service (NHS), which some now argue has the most comprehensive and integrated systems for health care quality assurance and improvement in the world.[7]

Events such as this are the "airplane crashes" of the health care industry -- the most serious and shocking manifestations of failure, which result in the most concentrated and visible harm to patients. Every airplane crash is carefully catalogued and painstakingly analyzed to learn lessons for the future.[8] However, this does not occur in health care. If we fail to investigate and learn from major failures in care, important opportunities for improvement likely will be missed, and the chances are surely higher that similar failures will happen again.


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