Transcriber: Annet Johnson Reviewer: Peter Van de Ven
For more than 10 years,
the third largest cause of death in the United States
has been attributed to preventable medical error.
The numbers associated with this are 300,000 to 440,000 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 and 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 are error makers? What are we?
Raise your hand if you've ever made a mistake.
(Laughter)
Look around the room.
Keep your hand up if you'd made one today.
(Laughter)
Okay?
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 grey 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 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.
(Laughter)
How about this regulation?
(Laughter)
Here's a rule that's clearly in conflict with another rule.
One of my most favorites, though, is this:
how we'd retrospectively, after the error has occurred,
try to hold people accountable
even in the worst possible circumstances.
(Laughter)
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.
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.
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.
So success is this, but failure -
Do you think the person thinks that failure is falling in the stairwell?
I can tell you from personal experience - because this happens to be my wife -
(Laughter)
that 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,
(Laughter)
and none of you got the Darwin Award, or you wouldn't be here.
(Laughter)
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, but 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 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 grey 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.
But what I do expect you to do is understand
that the conditions are 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 expected 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 judgment,
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 over 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.
Thank you.
(Applause)