I want to stay with this subject of how capable, experienced, professional people who know the consequences of their errors, still make them.
James Reasons article in the British Medical Journal sheds as much light on this subject as any. Reasons is the originator of the "Swiss cheese model" of risk management. It's worth a read in its entirety at the attached link.
Reasons' approach is to divide error into two broad categories. One focuses on the person and fixes accountability/blame on forgetfulness, inattention or other weakness. One of the flaws he identifies in the person approach is it de-couples the person from the context of the error and ignores two important facts....often the best people make the worst mistakes and there are recurring patterns of error in the same system. The other approach is to focus on the system...the conditions under which decisions are made. He further subdivides system errors into active(those made by people in the system) and latent(those inherent in the design of the system). Reasons argues for the systems approach, recognizing that good, capable people, ......experienced professionals.... still make mistakes. Creating defensive barriers and safeguards is a key element in the systems approach to error prevention. The "Swiss cheese" metaphor refers to the fact that every barrier has a weakness...a hole in the cheese....and that successive barriers need to be created in the system. He calls organizations that employ the systems approach "high reliability organizations"...those that have "less than their fair share of accidents."
Quoting from the article "Perhaps the most important distinguishing feature of high reliability organizations is their preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognize and recover from them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel areas. Instead of isolating failures, they generalise them. Instead of local repairs they look for system reforms"
Great leaders create a "high reliability" environment where, in spite of multiple barriers and best intentions, mistakes are expected. They generate trust by their ability to distinguish between "blameworthy" and "blameless" error.
James Reasons article in the British Medical Journal sheds as much light on this subject as any. Reasons is the originator of the "Swiss cheese model" of risk management. It's worth a read in its entirety at the attached link.
Reasons' approach is to divide error into two broad categories. One focuses on the person and fixes accountability/blame on forgetfulness, inattention or other weakness. One of the flaws he identifies in the person approach is it de-couples the person from the context of the error and ignores two important facts....often the best people make the worst mistakes and there are recurring patterns of error in the same system. The other approach is to focus on the system...the conditions under which decisions are made. He further subdivides system errors into active(those made by people in the system) and latent(those inherent in the design of the system). Reasons argues for the systems approach, recognizing that good, capable people, ......experienced professionals.... still make mistakes. Creating defensive barriers and safeguards is a key element in the systems approach to error prevention. The "Swiss cheese" metaphor refers to the fact that every barrier has a weakness...a hole in the cheese....and that successive barriers need to be created in the system. He calls organizations that employ the systems approach "high reliability organizations"...those that have "less than their fair share of accidents."
Quoting from the article "Perhaps the most important distinguishing feature of high reliability organizations is their preoccupation with the possibility of failure. They expect to make errors and train their workforce to recognize and recover from them. They continually rehearse familiar scenarios of failure and strive hard to imagine novel areas. Instead of isolating failures, they generalise them. Instead of local repairs they look for system reforms"
Great leaders create a "high reliability" environment where, in spite of multiple barriers and best intentions, mistakes are expected. They generate trust by their ability to distinguish between "blameworthy" and "blameless" error.
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