Abstract
A study was undertaken to examine how different hospital clinical settings compare in their capacity for physicians to attend to safety and employ a learning approach to error. Multiple qualitative methods were used to examine medical residency teams in the emergency department, surgery department, and the medical intensive care unit. The focus was on how physicians responded to errors that occurred and safety-related issues, and what features of the surrounding work context were associated with those responses. Observations of 3 separate medical residency team's everyday work were conducted over three 3-week spans, and follow-up interviews with select team members were conducted after each observational period. Evidence supported that physician capacity for attending to safety and error is shaped by structural features of the surrounding work context within hospitals, as well as the cultural dynamics inherent in physician groups working in a given clinical setting. Compared with the emergency department and surgery, the medical intensive care unit offered the greatest potential from a work setting perspective to have heightened physician attention to safety and error. This was due to its more collegial environment, the low permeability of its doctors and patients, more available physician downtime and group interactions, fewer disruptions, and greater work predictability. The emergency department had less capacity because of its intense workload, excessive disruptions, and high unpredictability of the clinical work found there. Surgery's capacity to deal with error and safety issues was adversely affected by the emphasis on hierarchy among surgeons, the high permeability of surgeons across hospital work settings, emphasis on individual blame when mistakes occurred, and workload. These findings highlight the necessity for health care organizations to conduct regular assessments of their clinical environments to help identify the workplace factors that shape clinician approach to safety and error. It also calls into question the singular, uniform approaches to enhancing quality and safety within health care organizations.