Abstract
Examination of operational failures in home healthcare could yield important insights into improving patient safety. This article presents a case study of work system breakdowns observed in the home healthcare setting. The findings suggest that the biggest areas of opportunity are failures stemming from (a) insufficient support from home health agencies and (b) inadequate coordination with patients and their families. Factors that impede organizations from learning from employees' experiences with operational failures and steps that managers may take to overcome these hurdles are discussed.
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