‘Lessons will be learned’ is an often-repeated phrase trotted out by government ministers and heads of organisations when things have gone dreadfully wrong. In this short article we explore the importance of action rather than words in developing a genuinely blame-free working environment, where people are open about making, correcting and sharing the learning from their mistakes.
I had a serious oil leak at home earlier this year. I reported it to the oil company who told me to tell my insurer, who told me to tell the Environment Agency. Six months on, after hundreds of man hours’ work and costs too scary to even think about, thankfully everything is resolved. Our oil provider has admitted liability and our insurers are dealing with their insurers… what I don’t know is how the oil company is handling the matter internally. Are they learning from what went wrong?
Mistakes happen all the time. Sometimes they lead to huge costs. Sometimes they result in egg-on-face embarrassment (I recently made a mistake in the first line of a client proposal for accuracy training!) and at other times, mistakes lead to catastrophe, even death.
In an article in the Daily Telegraph on 25th July 2018, Dr Kimberlie Garde wrote, “Every year, preventable medical error kills thousands. The only way to reduce this is to learn from each case. That will never happen if medics are too fearful of repercussions to be open about honest mistakes.”1
When he was Health Secretary, Jeremy Hunt spoke often about the need to bring about a profound change in the culture of the National Health Service, encouraging a no-blame culture where doctors and nurses can be open about mistakes they make without fear of retribution.
The Harvard Professor Dr Lucian Leape was reported as saying, “the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”2
In addressing the need for a no-blame culture, the National Health Service is beginning to embrace the ideas long since recognised in the aviation sector - that if you punish people for mistakes, you are complicit in a culture of cover-up and secrecy, which means that errors are repeated, and more lives lost.
Building an open, no-blame culture where everyone feels confident about owning up to mistakes and sharing the learning for wider benefit, requires trust. And that takes time. It needs more than mere words from a Chief Executive or a government minister. It needs proactive promotion and example. And we all play our part in the way we react when something goes wrong.
We can’t eliminate error, but we do have control over how we respond when a mistake comes to light. And we can train people in error-reduction skills. Leadership style is contagious so if you know your boss is going to react angrily when an error occurs, you’re much more likely to exhibit the same negative behaviour towards your own people when things go wrong - particularly at times of stress.
In our video blog, ‘How can you encourage a no blame culture?’, Accuracy Consultant Sue Duraikan offers practical advice on how to respond when an error does occur. Thinking in advance about how you need to behave is important. What you say and do at times of crisis when an error has occurred will impact the behaviour of others around you. Being calm and thinking through the options rather than ‘flying off the handle’ will always give better outcomes. And remembering that the person who made the error is likely to be feeling dreadful means considering their well-being too. As well as finding a practical way forward, you need to be thinking about providing emotional support to your colleague.
Later on, once the immediate repercussions have been dealt with, there is time to share the error experience more widely and reflect on what has been learnt. Owning the mistake means taking responsibility for not only making amends but also sharing the learning, so that everyone benefits.
No organisation can ever be error-free. But every organisation can - and should - actively promote a culture which understands that fact and knows how to learn from mistakes when they occur. Recognising the opportunity, drawing useful conclusions and sharing the learning makes each error valuable, if regrettable. And it puts a stop to a repeated pattern of error. It encourages a learning culture where people are valued for their contribution, however embarrassing, costly or deadly. I just hope the company which supplies my heating oil believes in this approach.
Vlog: How can you encourage a no blame culture?
In this short video, Accuracy Consultant Sue Duraikan shares practical ideas for promoting an open culture where people learn from their mistakes.
About Accuracy Skills
Whilst it is not possible to eradicate mistakes completely, it is certainly possible to develop practical accuracy skills which make error much less likely. If you’d like to explore how accuracy skills training works and sign up for free monthly accuracy tests, please visit the website and follow us. Or email us with your questions.
- The Daily Telegraph, 25th July 2018, page 22.
- https://www.gov.uk/government/speeches/from-a-blame-culture-to-a-learning-culture Global Patient Safety Summit March 2016
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