Hur lär vi oss av misstag? - En undersökning av inlärningsprocessen i svensk hälso- och sjukvård

Sammanfattning: In scientific investigations on how organizations can learn from their mistakes the perspective is usually that of the social engineer; the object is to prevent human errors through modeling the system in a certain way. The aim of this paper is to explore the learning process from a different standpoint than those usually applied in organizational learning and error theory. By studying the learning process in Swedish health care I seek to discover how theoretical presumptions affect the outcome in terms of what we actually learn. The theoretical framework draws on two major discussions in contemporary political science; the question of structure and agency and the question of whether to focus on formal or informal structures when explaining organizational behavior. The investigation shows that Swedish health care tend to understand human errors as a result of formal organizational structure. Such a view leads to insufficient explanations to why errors occur but is useful in producing preventative measures. On the other hand, a view that focuses upon the relationship between agent and context and which relates errors to the informal structure of the organization, offers a better insight into organizational behavior but makes the creation of preventative measures more complicated.