third-largest cause of death in the
United States has been attributed to
preventable medical error the numbers
associated with this are 300 thousand to
four hundred and forty thousand
fatalities per year it’s a shocking
number it’s a lot and it’s increasing so
we should think about this number and we
should look at it very carefully our
safety specialists have spawned what
they call the Global War on error and
out of this have emerged two fundamental
pathways the first pathway is mechanical
or mechanistic it’s putting
interventions or interlocks in place and
you’re probably familiar with many of
these these are the things that keep us
from making mistakes and these are
upstream management efforts pre-emptive
and for the most part they’re very
effective but there’s another side the
second side looks at the human aspect
the human contribution and what happens
with humans when humans make mistakes
well sadly our current methodologies are
pretty much dedicated to trying to
ascribe blame or error as causal and
what happens in this is we end up making
actions determining them or judging them
to be good or bad and at the same time
judging people as being good or bad the
problem here is that that doesn’t trap
error that traps people so what I’d like
to do now is I’d like to explore who we
are who our error makers what are we
raise your hand if you’ve ever made a
mistake look around the room keep your
hand up if you’ve made one today
so it’s kind of like Shakespeare said he
said to err is human and we’re all part
of the human club so if we’re going to
think about systems and we’re going to
say that a system has to be error-free
guess what I can guarantee that that
system will fail but let’s think about
this another way let’s think about how
people have to work inside of a gray
area that things aren’t really black and
white right and wrong in most workplaces
in fact most workplaces are complex and
the world and mother nature have a
tendency to hold their secrets close and
let them out sometimes at the worst
possible time let me give you an example
of how some some of these complexities
appear in normal work Chicago O’Hare
Airport sports this sign keep off red
line which I’d be really happy to do if
I could find the red line how about this
regulation I mean here’s a roll it
clearly in conflict with another rule
one of my most favorites though is this
how we Brett respectively after the
error has occurred try to hold people
accountable even in the worst possible
yeah so as we start thinking about who
we are as human beings we have to start
thinking about what the intention of our
people are so we hire people how many
people raise your hand if you’ve hired
somebody okay most of the time when you
hire somebody or your work colleagues
you look upon them as being good people
and they are good people and guess what
when they have an error or make a
mistake they’re still good people
they’re still well intended good people
you call yourselves caregivers most of
you have taken an oath to that effect so
we should think about who these people
are
let’s explore this this worker intends
to do the best that she can okay
now for full clarity this person is
standing with one foot on a ladder
another foot on a door that is not
secured and she’s painting over her head
to make sure that she gets paint on the
wall and not on the ceiling how does
this worker describe success at the end
of the day no paint on the ceiling
exactly right so success is this but
failure do you think the person thinks
that failure is falling in the stairwell
well I can tell you from personal
experience because this happens to be my
but she did not think that this was a
risky maneuver and she was doing the
best she could with what she had and I
bet every one of you has been in a
situation that is similar to this
and none of you got the Darwin order you
wouldn’t be here and if you did if
somebody did ascribe something like that
something as terrible as the Darwin
Award how would it make you feel inside
what would it take away from you and
this is what we’ve done with our current
processes of accident investigation now
I’ve been doing accident investigation
for over 20 years I’ve seen a lot they
usually call me when there’s a fatality
and what I’ve got to tell you is this
that our approach has been fundamentally
dispositional what I mean by that is
we’ve looked at the disposition of
people we’ve tried to say that they were
bad people and sometimes that makes us
feel good afterwards because gosh knows
I’m not a bad person
so what happens when they are successful
with an innovation the opposite is true
if they’re successful with the
innovation and my wife doesn’t get paint
on the ceiling and it all ends up on the
wall then we say you were thinking
outside the box and we reward that but
it’s the same adaptation so the same
adaptations that result in success
result in failure so what I’m suggesting
is this dispositional idea of judgment
doesn’t really move us toward learning
and the real currency that we have in
safety to improve safety in any
workplace is information and if we cut
that conduit of information off if we
ostracize people and make them feel bad
we’re going to lose that source of
information so what we’ve done is we’ve
looked at this a very different way and
my research has shown that what we need
to do is focus on the conditions that
influence decisions and actions we have
to ask a question that is more
situational in nature than dispositional
and that question is pretty simple why
did it make sense for good people to do
what they did and in order to understand
that
we’ve got to look at the conditions that
supported decisions and actions we
create a thing that we call a network of
influences map and we call it a network
because we see these things these
conditions as nested and networked and
influencing each other as well as
influencing the individual we’ve all
seen it
sometimes we’re influenced for the
better sometimes we take less risk for
example sometimes we’re influenced to
take more risk and that’s not
necessarily for the worse sometimes we
have to take risk because there is no
zero risk option and that’s another
thing that we’ve got to understand that
lives in this gray area so this is just
one example from one of the accidents
that we did and just to give you an idea
what this grows into it grows into
something like that and I don’t expect
you to read that for what I do expect
you to do is understand that the
conditions are really really extremely
diffused within our system and they’re
very rarely depicted in a way that
leadership can understand much less that
the field can understand so out of this
process what we expect is this we expect
that our leaders who are really imbued
with one responsibility and that is to
create a workplace wherein workers can
be safe wherein workers can be
successful our leaders are imbued with
that responsibility when we think about
a safety function in our organization
our responsibility as safety managers is
to deliver information to that
leadership so that they can make
informed decisions if they’re aware of
the conditions in the workplace that
make error more likely they’re going to
be able to address the conditions
instead of creating second victims by
admonishing the workers and that’s the
goal so what do we say about this we
look at it like this I hate to divide
things in binary opposites but sadly
this process of accident review has been
forced into this place if we stay on the
side of judgments
we end up infusing pain distrust and
silence emerges in our system but if on
the other hand our focus is learning and
the questions that we ask move to that
learning place the difference is
profound because then we have trust we
have sharing of information and the
system is richer for it now as I
mentioned I’ve done accident
investigation for 20 years and I bet
some of you are thinking what about
accountability well I can say this about
accountability organizations after an
accident are accountable to learn as
much as they can to prevent the next
accident but let me share one more thing
with you I’ve done a lot of interviews
in those last 20 years hundreds if not
more well hundreds at least and in those
interviews I can tell you one thing
about the people that I’ve interviewed
there is no way that any system can hold
them more accountable than they hold
themselves [Applause]