tl;dr: In this post, Mark categorizes mistakes into two main types: those that are preventable and those that spur innovation. He elucidates how recognizing the difference between these types can inform an organization's approach to error management. By doing so, companies can create a culture that both minimizes preventable errors and capitalizes on mistakes as opportunities for innovation.
Thanks to the podcast “Unbound with Chris DuBois” for hosting me and for sharing this clip. This clip only covers two of the three types of mistakes — my mistake!
You can hear the full episode but I'm sharing a short clip from the episode below.
Hat tip to HBS Prof. Amy Edmondson for the framework… about different types of mistakes or failures.
Here is the clip, with the transcript below…
Mark Graban: Edmondson puts out a framework base, it's really helpful, three categories of mistakes. There's one category of mistakes that we could say I would add in a non-judgmental way. Mistakes that should never happen. These are things we know how to do the work a certain way and we have procedures and structures in place.
When I was growing up, when I was a kid in Detroit, one of the catastrophic plane crashes of the era. On takeoff from the Detroit airport, a Northwest Airlines plane crashed and killed all, but one person on board because the captain and the co-pilot didn't set the flaps to a certain position. The plane couldn't get enough lift, hit a light pole, ended up crashing.
That's the type of mistake, for one, you can't hide or cover up that mistake, unfortunately. Aviation has such a strong culture of learning from, not just mistakes that are catastrophic, but from near misses and putting procedures in place. Hopefully, a plane never crashes again because of that failure mode, if you will.
A lot of medication errors and harm that occurs in hospitals, I would probably put in that same category. Procedurally, these errors are preventable. Then there's a middle ground, the gray area, to come back to.
Then there's the other end that you're touching on, Chris, on the edges of innovation. What she calls “intelligent failures,” where we can fail forward. I try to emphasize, if we're testing an idea, let's do a small test, so a small “failure.” A small mistake can prevent larger ones. That's part of the iterative entrepreneurship Innovation cycle.
Here is text from the section of my book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation, where I discuss this and cite Edmondson.
Shift Away from Punishment to a Positive Path
“Not all mistakes are created equally. Some mistakes cause more harm or damage than others. But the amount of harm is not the criterion we should use to decide if punishment is fair or warranted. See more about the “Just Culture” methodology in Chapter Six.
In some companies and circumstances, we can celebrate mistakes as an opportunity to learn and improve, even when there is a significant financial loss. In other situations, we must work diligently to prevent mistakes that cause harm and death. In part, we can prevent major mistakes by learning from small mistakes (or close calls) of the same variety that do not cause harm. Aviation does this exceedingly well. Healthcare generally does not, as discussed more in Chapter Five.
Edmondson distinguishes between three types of mistakes:
- complex, and
In situations where people are doing novel and innovative things, leaders can welcome intelligent mistakes, if not celebrate them, as discussed in Chapter Seven. Some mistakes are completely preventable in known ways, if people are able to follow their standard process. Organizations can prevent many mistakes through approaches like checklists and other forms of mistake-proofing, as discussed in Chapter Four.
An example of a complex mistake might be a bad surgical outcome resulting from an unforeseen combination of events, leading to an unexpected mistake. In healthcare, preventable mistakes can be fatal, like performing a surgical procedure on the wrong patient or giving the wrong medication. Edmondson says, “Neither preventable nor complex failures are worthy of celebration.”[i]
In truth, systemic factors cause most mistakes. If we attribute a mistake to simple human error, we wouldn't shrug it off and say, “Well, we're all human; we all make mistakes. What more can we do?” We do the right things. We don't punish. Instead, we choose to be kind and constructive. Actually, kindness is constructive, as discussed further in Chapter Three. We must learn from our mistakes and improve.
Firing a person for a mistake without addressing the systemic causes, especially those factors out of their control, dooms their replacement to the same mistake. Thomas J. Watson, the founder of IBM, was asked if he would “fire an employee who made a mistake that cost the company $600,000.” He replied,
“No, I just spent $600,000 training [them].”
Watson wanted IBM to benefit from that investment, owning those elessons learned instead of letting another company hire away that experience and knowledge.
When we stop punishing people for mistakes, we start a virtuous cycle of increased learning and psychological safety. We don't do it to be nice; the goals are fewer mistakes and better business results.“
[i] Edmondson, Amy C., The Fearless Organization (Hoboken, NJ: Wiley, 2018).
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Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation: