I’m not sure why “error” was put in quotes since this seems like an actual error, not a quote-unquote error:
When people talk about human error, they often seem to miss the point. They think calling something human error is an excuse. No.
Human error is GOING to happen, because we are fallible. That’s why we need good systems, tools, and processes and we can’t just ask people to “be more careful” and we can’t just blame them after an error occurs.
As the article describes, a hotel employee was mixing chlorine and swimming pool chemicals something went wrong, releasing gas. This sent five people to the hospital, where all were expected to recover and be unharmed.
Speaking at around 6pm yesterday, Mr Flynn said: “A member of staff got the mixture wrong in the plant room, releasing the chemical.
“It was human error.”
It seems like a factual statement to say that the mixture was wrong… and that’s about it.
Ascribing it simply to “human error” often implies “well, there’s nothing more we could have done… it was human error, don’t blame the management or the organization… blame that individual. We’ll punish that person and move on.”
However, if we ask “why was the mixture wrong?” (and keep asking why) there are possible systemic factors including (just guessing here):
- Unlabeled or poorly-labeled containers that led to the wrong chemical being used (a system problem)
- Lack of proper tools for measuring the chemicals (a system problem)
- Poorly trained staff (a system problem)
- The person doing the work was rushed or distracted (a system problem)
These are all system problems. The Just Culture methodology and this flowchart provide better problem solving tools than asking “who screwed up?” Click for a larger view… in most instances, the flowchart points to “system problem” and there are just a few circumstances where individual punishment is recommended.
Leaders need to be proactive to prevent errors and situations like the one described in the article.
There’s another blaming statement:
“One of the leisure club operators got the mixture wrong when preparing some chemicals and there was a reaction, so we evacuated and alerted the fire brigade.”
Rarely do we hear about what the leaders and the organization did wrong. Rarely are leaders held accountable for the results of what happened as a result of the system… and top leaders are responsible for the system, as Dr. Deming so clearly pointed out.
Recently, the CEO of the South Korean company that operated the ferry that sunk and killed 188 resigned and was arrested. The boat was allegedly overloaded with cargo – something that is quite likely a system error as opposed to being one captain’s fault. How did company policies, targets, training, and systems contribute to that?
Back to the hotel article:
He added there had never been an incident of this nature at the hotel before.
He said: “We have been here 19 years and this has never happened before so we have got a good record.
“The operator obviously made a mistake.
“We’re all human. If you’re not absolutely careful these things can happen.”
Not having an incident for a long time is NOT a good predictor of an error-free future. We see this in many well-known cases of medical error… a person with a sterling track record is involved in an accident and gets blamed, usually unfairly.
You can see the undeserved faith put into “being absolutely careful.” Things can go horribly wrong even with an absolutely careful person. As I’ve said before… being careful is a good start. It’s helpful, but not sufficient for quality and safety.
What is your organization doing to reduce blame? Are you using “Just Culture” in healthcare or other industries? Let me know what you think by leaving a comment.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.