Error, Error, Error

High-performing organizations strive for perfection in nearly everything they do, right? Particularly when it comes to operations-critical work or safety-critical work where serious performance failure is not an option organizations often go to great lengths to help ensure that performance will meet expectations. But, does this process sometimes place too much emphasis on the employee, and if so, is it possible to set employees up for an eventual failure by placing too much on their shoulders?

In many high-performing organizations there is an emphasis on human performance. After all, the human should be considered the most important part of the system (at least in my opinion), particularly if there is a high-degree of human involvement required for task completion. Is it possible, though, that in the zeal of striving for top performance that employees may be set up to make errors, perhaps based on the operational environment itself, the design of the work system, or other human factors that impact task accomplishment? And when performance variability exceeds desired parameters (in other words when errors occur) are employees reprimanded and simply told to “try harder” or are they simply told, “Don’t make that mistake again?” If so, these strategies may offer limited results and if there are system problems the same mistakes may happen to other employees. If these are the ways leaders and managers respond to error or failure they may be missing opportunities for improving the system as a whole.

So, what is an organization to do, then, if leaders want to improve system performance (which, by the way, should include human performance)? Here are some ideas:

 First, try to identify the boundaries of performance variability and where they stop. What makes a job safe versus unsafe and what level of error or variation in task accomplishment are you willing to tolerate before safe operating boundaries are crossed? Also, try to determine the difference between a willful violation of procedure or policy versus an error. Humans will make errors. That is somewhat easy to understand, but an error is often different from a willful violation. A sound analysis process with open communications and a high-trust relationship between employees and supervisors, managers, and leaders may help identify these issues and solutions for correcting them.

• Second, when repeat errors occur consider asking a few questions, such as, “Is this employee skilled and competent?”, “Might it be possible for others to make same error?”, and “Is it the employee, or the task description, process, tools, equipment, or the environment that could be a causal factor in the error?” The answers to these questions may help reveal opportunities for system improvement.

 Third, consider asking whether or not all error is bad. Is it possible to learn from error? Oftentimes the answer is “yes.” However, one of the challenges is detecting and correcting the error at the micro-variation point before it cascades downstream or ripples outwards to impact other areas. Perhaps rather than thinking too hard about error “elimination” consideration may be given towards building a process for error detection, correction, management, and recovery. By using a process like this teams may be able to catch errors early in the process before they propagate throughout the system and lead to larger failures. Building a defense-in-depth with multiple safety controls may help as well.  

 Finally, consider using a debriefing process to help learn from not only failures or errors, but also from successes. Sure, it is possible to learn from failure, but oftentimes successful events offer great learning opportunities for future successful, repeatable processes. Unfortunately, many organizations often pay more attention to failure than success and may miss opportunities for learning.

So, when trying to improve operations and safety performance try to consider the situation and context itself before simply blaming the human without a thoughtful analysis. After all, is it possible to make a mistake? Have you ever walked from one room to another and forgot why you entered the other room? Have you ever thought you had misplaced your glasses or sunglasses while they were on your head? Have you ever driven a few miles yet didn’t remember passing familiar places? If this hasn’t happened to you, have you heard stories of it happening to someone else? These are simple examples that we can use to remind ourselves that sometimes even simple tasks can involve errors. While repeat errors and large failures are things that organizations should strive to avoid or minimize within the organization, it may be the strategies used to avoid or minimize them that are flawed, not necessarily the people within the system. Strategies that consider systems and processes, and that consider people as an important part of that system may offer some help.

Thanks for reading and have a great, productive, and safe day! 

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