Mistakes, I’ve made a few, but then again…

Another fascinating article about mitsakes and the value (or otherwise) of a Blame Culture…

Another serious weakness of the person approach is that by focusing on the individual origins of error, it isolates unsafe acts from their system context. As a result, 2 important features of human error tend to be overlooked. First, it is often the best people who make the worst mistakes—error is not the monopoly of an unfortunate few. Second, far from being random, mishaps tend to fall into recurrent patterns. The same set of circumstances can provoke similar errors, regardless of the people involved. The pursuit of greater safety is seriously impeded by an approach that does not seek out and remove the error-provoking properties within the system at large.

and this…

High-reliability organizations can reconfigure themselves to suit local circumstances. In their routine mode, they are controlled in the conventional hierarchic manner. But in high-tempo or emergency situations, control shifts to the experts on the spot—as it often does in the medical domain. The organization reverts seamlessly to the routine control mode once the crisis has passed. Paradoxically, this flexibility arises in part from a military tradition—even civilian high-reliability organizations have a large proportion of ex-military staff. Military organizations tend to define their goals in an unambiguous way and, for these bursts of semiautonomous activity to be successful, it is essential that all the participants clearly understand and share these aspirations. Although high-reliability organizations expect and encourage variability of human action, they also work hard to maintain a consistent mindset of intelligent wariness.

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About dwighttowers

Below the surface...
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