Dick Davidson reminds us in the foreword to this important book that the public perception of the American hospital as a partner in its community, supporting “kindly Marcus Weldon MD” of 1970s television fame in the US, has changed. Although the nurses and doctors in the emergency room still seem heroic, the hospital seems more like a bureaucratic barrier getting in the way of “good people trying to help people”. Systems are now in place in the US and the UK for the detection and prevention of clinical error, but the detection and prevention of healthcare managers' errors has not, until publication of this book, received the same attention.
The book aims to be a first step towards acknowledging and examining mistakes in healthcare management. Although their consequences are not as immediate as for clinical error, management errors may affect the health of whole communities. The book recognises that it is not easy to define management error. It offers some options here, emphasising a thorough review of evidence before a decision is made, and distinguishing error from intentional wrongdoing. The target audience is chief executives, senior managers and clinical managers (because clinical error, it argues, can become a management issue), and perhaps also risk managers, clinical governance staff (in the UK) and ethics staff (in the US). The book comprises six initial thought pieces followed by seven US‐based case studies. The content is mainly relevant to US, but a reflective chapter on UK facilitates the transfer of some lessons from the case studies.
The thought pieces cover some sources and types of error (eg, of commission and omission), levels of disclosure, coping strategies for individual errors, methods of improving management performance, and systems and policies for managing management errors. Other chapters look in detail at the dimensions of the context of managerial mistakes, and present alternative or complementary taxonomies of sources, types, and ways of disclosing, managing, correcting and preventing management mistakes. There is a reflection on the lessons from medical mistakes, and recognition that there is management responsibility for both the antecedents and the consequences of clinical error. A final reflective chapter considers accountability for management mistakes, suggesting that the “no‐fault society may actually have some limits”.
The case studies are generally lively and convincing. They cover the management response to medical error, management of a nursing shortage, problems with IT procurement, inept strategic planning in the development of a new hospital, mistakes in public relations after a death caused by equipment failure, problems with clinical governance, specifically, in engaging the board in providing “loyal sceptic” (“iron sharpens iron”) support for the CEO and an account of a failed hospital merger. Although the cases are all US based, the UK review of selected cases highlights the UK national systems for reporting mistakes and sharing lessons, and points out that in the UK, chief executives of healthcare organisations are now legally accountable for mistakes made by their staff. The final chapter sums up the lessons learnt from both case studies and the thought chapters.
The book makes a commendable start in dealing with healthcare management error. It emphasises the need to be open and honest, alongside acknowledging that complete candour may not always be useful. It does not draw explicitly on concepts from organisational learning which could point to the links between robust systems for detecting and preventing error using single‐feedback loop learning and double‐feedback loop goal changing learning. An open learning culture—for example, using the method of Argyris and Senge, needs to include the possibility of innovation. The definitions of management mistakes are not fully convincing, because the nature of management evidence means that management mistakes can be made sense of in different ways from different perspectives, and this, the political dimension, is not much discussed. Some of the differences in principle between management and clinical mistakes are usefully dealt with. I would recommend this book for all senior healthcare managers interested in learning from mistakes.