David A. Hofmann and Michael Frese

摘要

A short example, buried on page 263 of these 12 chapters about organizational error graphically illustrates what animates the authors who contributed to this edited volume. In the year 2006, six infants at a Midwest hospital were given a 1000-fold overdose of blood thinner and three of them died, because "the system was too reliable." That sentence makes no sense! And yet the deaths happened. The overdoses were administered by five different nurses. And the hospital had set up a safety program to reduce medical errors. A close reading of these chapters, authored by 21 experts, renders that calamity more sensible by redirecting our attention away from error prevention toward error management. Rare as that overdose event is, the cumulative analysis in these chapters, spanning individual and collective moments, begins to account for its genesis and for the genesis of deviations that are much more common.