Learn from your mistakes… or repeat them?

Human Error Prevention behavior contributes maximum benefits to an organization when it becomes part of the organization’s culture.  That is, everyone uses the tools and lexicon of error prevention as part of their mode of operation.  In addition, in an error prevention culture, everyone shares stories about mistakes that happen or are avoided – without fear of negative reprisal – so that others can learn organically.

In order to achieve the ongoing success – and, hence, the benefits of error prevention behavior – it is important for executives, supervisors and employees to operate in a “Just Culture” environment.

What is a Just Culture?

  • One that supports the discussion of errors so that lessons can be learned from them.
  • One in which frontline staff feel comfortable in disclosing errors including their own while maintaining professional accountability.

It is a fundamental truth that good organizations cannot operate without accountability.  Does this notion of No Blame threaten this business truth of Accountability?

Well, no, the two are actually complementary.

Accountability typically involves examining the technical reasons for a success or mistake.  Often times this is called Root Cause analysis and is applied to examining why a mistake was made.  Root Cause analysis seeks to find that singular reason for a mistake or inefficiency so that corrective procedures or “things” can be applied in the future to avoid the same mistake or inefficiency.  Many times, the result is that a person is held accountable and is reprimanded or fired for making a mistake.

Accountability based on a singular cause rarely includes the notion that root causes might exist.  The additional causes just might be human factors that are not considered in most root cause analysis.

A No Blame culture simply means that, before coming to the conclusion to reprimand or fire an employee, human factors are examined too.  The conclusion might very well be that an employee loses their job, but at least the whole situation has been examined before that conclusion is reached.  But, a different more positive conclusion could be that the human factors that were in play provide an insight/reason that exonerates the employee and, indeed provides an opportunity for the company to learn what to do about a human factor situation in the future.

The following story perfectly illustrates how Accountability and No Blame work together.

Medication administration errors are a problem in hospitals.  One hospital established a policy – based on factors such as legal, insurance cost and hospital reputation – that, as the final person involved with administering medication, a nurse who administered the wrong medication was held accountable and was immediately terminated.

After the Chief Nursing Officer became aware of the No Blame approach, she began asking human factor questions before making a termination decision.  Soon enough, an administration error happened, and the RN was called into the Chief Nursing Officers office.

The RN fully expected to lose her job.

The CNO asked about the human factors and discovered that the RN’s were under extraordinary stress and were fatigued by working excessive hours with reduced staff.  The RN’s frequently missed meals due to their workloads so their decision making was jeopardized.

The CNO did not fire the RN but rather thanked her for being honest about her situation.  The CNO determined that the hospital needed to increase staff and be innovative about the work hours for the staff.

Medication administration errors went down, and nurse terminations were greatly reduced.

On can conclude that blending Accountability with No Blame is a powerful way to generate a culture that is more efficient and profitable.  With the added benefit that the organization does not lose valuable human assets unnecessarily.





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