My favorite book of all time, personal and professional, is The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA by Dr. Diane Vaughan. Dr. Vaughan is a sociologist and brought a sociologist's perspective to the engineering world of NASA. Perhaps you have heard about "production pressures", "structural secrecy", or "normalization of deviance". All concepts applied to the Challenger disaster and later the Columbia disaster. But wait - do hospitals have any production pressures? How about continuing to do elective surgeries when there are no beds available, or not going on ED diversion when full? Any structural secrecy in your hospital? How about peer review, incident reports maybe. And finally normalization of deviance, my hospital just started medication administration using barcodes etc. In the first week we found that nurses were making color copies of their badges to use for medication barcode scanning. This practice, a deviance from the intended process, became normalized in less than a week. Just think of all the other processes that have generated work arounds, even though they generate known safety issues.
Amazing, all risk mangers should read this book.
BQ