When we think about an adverse event and error or an accident as witnesses, we get to see the outcomes of a long stream of actions and processes. People try to navigate their daily work in a manner that is meant to be both effective and efficient. They see problems and impediments to their daily work and the expectations that are placed on them and they do the best they can to try and come up with options and sometimes workarounds to the things that seem to be in their way. In most cases they are trying to achieve good results, but sometime the work arounds result in unexpected outcomes that only in hindsight make it clear that the decisions made were less than optimal. In those instances we tend to blame the individual for the outcome and yet we fail to consider the processes that people were using.
Let’s consider and somewhat silly example….
Let’s say that I have been assigned to change all the lightbulbs in a very large conference room. It’s a big room and it is going to take me the entire week to complete.
As I go to the closet to pull out the ladder I need to use, I notice that the ladder is broken. It is unstable and won’t stay locked in place as I try to climb each rung of the ladder. In the closet is a nice large roll of duct tape and with a bit of work and ingenuity I am able to use the tape to seemingly make the ladder stable enough that I feel comfortable using it. So for the first few days of the week I go up and down the ladder changing the light bulbs.
My supervisor happens to stop by and notices what I have done and congratulates me for my innovative use of duct tape and mentions that I even save the company money because we don’t have to purchase a new ladder. He is thinking of putting me in for a commendation for my hard work and innovative use of duct tape.
Everything is going just fine until Friday (the fifth day I have been happily using my ladder and getting the lights changed) when I climb my ladder and the tape suddenly rips and the ladder crashes to the ground taking me with it. In the fall I break my femur and have to be hospitalized.
As my coworkers and supervisor consider what has happened, they wonder about how silly it was to think that I could use duct tape to hold a ladder together.
Think about this scenario. Earlier in the week I was an innovative, cost saving hero. Later in the week I am a silly goat.
Of course….the process that I used the entire week was the same. Only the outcome was different. This is why it is so important to not view errors by the outcomes. Most important is to understand the processes that were being used prior to the adverse outcome. Often, various forces in an organization lend themselves to people using processes that are not ideal. We allow those processes to go unheeded until there is an accident (often a very predictable accident). Then we look to blame the person who was on the receiving end of those many flawed processes.
That blame won’t make the system safer. It will instead leave those flawed process to set up the next person for failure.