Organisational learning in the prevention of human error

One of the major determinants of the safety of any organisation is its ability to learn from its failures. Amy Edmondson, in her paper titled Learning from failure in health care: frequent opportunities, pervasive barriers, pointed out that this learning is as important for ‘major, highly visible crises or accidents‘, as it is for minor errors. This, she explained, is because ‘when small failures are neither identified widely, nor discussed and analysed, it is very difficult for larger failures to be prevented‘. For this reason, she stressed that ‘an organisation’s ability to learn from failure is measured by how it deals with both large and small failures’.

It was a mistake. Thomas Hawk on Flickr. https://www.flickr.com/photos/thomashawk/28159107713/

According to Edmondson, the major factor that enables an organisation to learn from failure is its ability to create a learning environment – an atmosphere in which ‘people feel comfortable and capable of speaking up with interpersonally difficult observations and questions’. She however maintained that such an environment can only be ‘created locally, one clinical area or patient care unit at a time’, and not by ‘topdown mandate‘, explaining that all organisations consist of multiple microcultures built around small groups. She further described a learning environment as ‘one in which bearers of bad news are embraced rather than shunned‘, emphasising that ‘without the disruptive questioner, organisations cannot learn’ or appreciate the value of the ‘learning content‘ of bad news.

By Crankelwitz at English Wikipedia, CC BY-SA 3.0, Link

To enable a psychologically safe learning environment to emerge, Edmondson advocated for the institution of a ‘formal blame free reporting policy’, and for a change in ‘the language used in the organisation’, moving away ‘from threatening terms such as errors and investigations’ to ‘more psychologically palatable and productive terms such as accidents and analysis‘. She also urged leaders of organisations to provide ‘a compelling vision of the destination’, and ‘a team based learning infrastructure’.

The failure of love. Giveawayboy on Flickr. https://www.flickr.com/photos/giveawayboy/26646010542

Whilst establishing a learning environment is a worthy objective, Edmondson pointed out that there are major barriers that discourage hospitals from learning from failure. Amongst these are the culture of medicine which ‘generally discourages admission of error’, and reduces the ‘potential to learn from mistakes, both consequential or not’; the ‘interpersonal climate‘ that hinders frontline workers from ‘speaking up with questions, concerns, and challenges’; and the design and culture of workplaces that encourage responding to failure with ‘quick fixes‘ rather than with ‘root cause analysis and systematic problem solving‘.

Disaster Movie. Sandra Strait on Flickr. https://www.flickr.com/photos/aceo/24592305619/

We have now concluded our Shortcuts and Pitfalls journey, and hoping it has been a worthwhile trip.

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