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Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures. Health Affairs. 2004;23(3):103.

Link

Review /Overview

Groups

Organisations - healthcare

Cultures - organisational

Key commonalities : 1 Longstanding, 2 Well known but not well handled, 3 Cause immense harm, 4 Lack of management systems, 5) Repeated incidents 6.Not discovered by 'quality assurance' systems, Exacerbated by 'club culture'; fragmented knowledge and responsibility and a high capacity for self deception

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