What happens when a mistake is made in your organization? How do you react when an error occurs?
A lab specimen gets mislabeled. The wrong product is shipped to the wrong customer. A patient is injected with the wrong medication.
These are moments that matter.
Does emotion take over or do we stay calm?
How do we respond? Have we thought this through and planned this out, or do we just react?
People often talk about “human error,” but what does that really mean and how does it color our response?
When there's a problem, I often see three common types of responses and reactions.
1) That human made the error, punish them
Managers are often quick to jump to blaming “human error” and pointing to the individual human who screwed up.
We might even punish that individual – they might be reprimanded, suspended, fired, they might lose their license or even be thrown in jail.
Many of these punishments are an outrage and an injustice. Many of these errors are systemic in nature and different people would have made the same mistake in that same scenario. This is often an illustration of what Dr. W. Edwards Deming called a performance review “lottery.”
Some people win the lottery and luck out to never be put in that particular bad position. Some people lose.
The “bad apples” mindset says we should identify the humans who make errors and get rid of them.
Wouldn't it be nice if we could identify the bad apples and fire them before they made an error?
2) Humans make errors, so what can we do?
I sometimes hear people realize that we're all human and we are all prone to error (especially so when we're in bad systems).
But, some of these folks throw up their hands and ask, “Well, what can do we do?”
We shouldn't just name, shame, and blame… but we shouldn't be fatalistic, either, and say “these things are bound to happen.”
I hear that a lot in healthcare, sadly — these things are bound to happen. Our patients are sick, they're going to get infections. Well, what can we do, a certain number of wrong site surgeries will happen. What can we do?
3) Humans are error prone, so design better systems
This is the road less traveled.. but the one I think we should take. Don't throw people under the bus, don't throw up your hands… improve processes and the systems in which people work.
I was re-reading some of Dr. Deming's classic book Out of the Crisis the other day and he writes with such clarity about the difference between “common cause” errors and “special cause” errors.
Special cause errors are things that can be attributed to a person and their lack of skill and statistically significant lack of performance.
Common cause errors are things are caused by “the system” in which people work.
What are systemic causes or contributors to errors? Things like:
- Not having enough time to do your work (overburden, rushed work)
- Bad equipment, supplies, or medications
- Having the wrong technology
- An environment where people are afraid to speak up (they work in fear)
- Poor training
It could be a very long list.
Deming was very clear that only MANAGEMENT has the responsibility to fix the system. We can (and should) certainly engage the people who do the work in improving processes and systems, but it's management's responsibility.
Front-line staff get fired all the time for “making mistakes.” Managers, leaders, and senior leaders rarely, if ever, get fired for their role in creating (or tolerating) a bad system. But, like Dr. Deming said, even managers and CEOs are part of a system (that system includes the law, regulatory environment, etc.)
I often use this slide in my training and discussions… two quotes about why we need better systems, coming from a Lean & Toyota perspective (left) and a patient safety movement perspective (right):
Does your organization take the third path? How do we help others see the benefits of taking the road less traveled?
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