Hospitals as cultures of entrapment: A re-analysis of the Bristol Royal Infirmary

California Management Review

Volumn 45, Issue 2, 2003, Pages 73-84

  Weick, Karl E ^a   Sutcliffe, Kathleen M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0037412612     PISSN: 00081256     EISSN: None     Source Type: Journal    
DOI: 10.2307/41166166     Document Type: Review

References (58)

1. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, To Err Is Human: Building a Safer Health System (Washington, D.C.: National Academy Press, 2000).
2. nd edition (Oxford: Butterworth-Heinemann, 1997: 47).
3. I b i d.
4. Learning from Bristol (Crown Copyright 2002), p. 266.
5. See Chapter 1 in E.H. Schein. Organizational Culture and Leadership (San Francisco, CA: Jossey-Bass, 1985).
6. K.E. Weick and K.M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity (San Francisco, CA: Jossey-Bass, 2001), pp. 121-122.
7. Learning from Bristol [see note 8], p. 4.
8. All details concerning the Bristol Royal Infirmary are taken from the Bristol Royal Infirmary Inquiry Final Report. The Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995, Learning from Bristol, Presented to Parliament by the Secretary of State for Health by Command of Her Majesty, July 2001, Crown Copyright 2001. The inquiry was conducted between October 1998 through July 2001. The magnitude of the inquiry is daunting. The final printed version of the report is 530 pages and includes two CDs of raw data. The investigators received written evidence from five hundred and seventy-seven witnesses (two hundred and thirty-eight of those witnesses were parents). They also received and reviewed over nine hundred thousand pages of documents, eighteen hundred medical records, and took oral evidence for ninety-six days. They commissioned a hundred and eighty papers that were presented at seven different seminars. There are no restrictions on quoting or using the report. See www.bristol-inquiry.org.uk.
9. Learning from Bristol, op. cit., p. 23.
10. Ibid., p. 25.
11. Ibid., p. 105.
12. Ibid., p. 105.
13. Ibid., p. 175.
14. Ibid., p. 104.
15. Ibid., p. 139.
16. Ibid., p. 136.
17. Ibid., pp. 4-5.
18. Ibid., p. 4.
19. Ibid., p. 4.
20. Ibid., p. 134.
21. Ibid., p. 134.
22. Ibid., pp. 134-151.
23. Ibid., p. 136.
24. Ibid., pp. 138, 210.
25. Ibid., p. 141.
26. Ibid., p. 4.
27. G.R. Salancik and J. Pfeffer, "A Social Information Processing Approach to Job Altitude and Task Design," Administrative Science Quarterly, 23/2 (June 1978): 224-253.
28. Ibid., p. 231.
29. Ibid., p. 235, footnote 3.
30. Learning from Bristol, op. cit., p. 266.
31. Ibid., p. 161.
32. Ibid., p. 161.
33. Ibid., p. 4.
34. Ibid., pp. 239-240.
35. Ibid., p. 164.
36. For examples, see M.L. Tushman and C.A. O'Reilly III, Winning through Innovation: A Practical Guide to Leading Organizational Change and Renewal (Boston, MA: Harvard Business School Press, 1997), pp. 132-141; J. Ross and B.M. Staw, "Expo 86: An Escalation Prototype," Administrative Science Quarterly, 31/2 (June 1986): 274-298.
37. For examples, see M.L. Tushman and C.A. O'Reilly III, Winning through Innovation: A Practical Guide to Leading Organizational Change and Renewal (Boston, MA: Harvard Business School Press, 1997), pp. 132-141; J. Ross and B.M. Staw, "Expo 86: An Escalation Prototype," Administrative Science Quarterly, 31/2 (June 1986): 274-298.
38. Sir Cyril Chantler, former Dean, Guy's, King's and St. Thomas's Medical and Dental School, cited in Learning from Bristol, op. cit., p. 355.
39. D. Vaughan, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA (Chicago, IL: University of Chicago Press, 1996), p. 281.
40. A.C. Edmondson, "Psychological Safety and Learning Behavior in Work Teams," Administrative Science Quarterly, 44/2 (June 1999): 350-383.
41. M. Paget, The Unity of Mistakes: A Phenomenological Interpretation of Medical Work (Philadelphia, PA: Temple University Press, 1988).
42. Learning from Bristol, op. cit., p. 74.
43. Ibid., p. 257.
44. Ibid., p. 16.
45. Ibid., p. 302.
46. Ibid., pp. 68, 201.
47. Ibid., p. 201.
48. Ibid., p. 202.
49. Ibid., p. 161.
50. Ibid., p. 268.
51. Ibid., p. 273.
52. Ibid., p. 163.
53. Ibid., p. 148.
54. Ibid., p. 247.
55. Ibid., p. 247.
56. Ibid., p. 272.
57. Ibid., p. 248.
58. Ibid., p. 4.