Duke "Anatomy of an Error" course: is every mistake human error or a process defect?

I've been thinking about how to teach "mistake appreciation," for lack of a better term, to knowledge professionals. As such, I am very attuned to discussions of errors/mistakes/failures, including definitions and prescriptions. So I was very interested when @whatsthepont shared the Duke "Anatomy of an Error" online course (discussed earlier this week). Here's a graphic from my recent materials (adapted from Amy Edmondson's work):

Health care is a business that sits squarely in the complex domain - the center of the spectrum. And as you can see, failures are unavoidable. How important, therefore, is it to teach people involved in this process how to understand, prevent and learn from errors? Very important, of course. So the Duke course is admirable.

However, my concern about the course is that it seems to hold a point of view that if workers acted carefully enough, and process designers were thorough enough, that errors in health care could be eliminated completely. Here's an example of what I'm talking about from the course:

Because humans are fallible, we must rely upon systems and back-ups to prevent or detect errors before they can cause harm. Unfortunately, our systems are not always designed well to achieve this. System and design factors that can lead to bad outcomes include:

Complexity:

Too many steps Too many people (communication issues)

Workload:

Too heavy or too light (performance is best when workload is moderate) Too much reliance on human vigilance/monitoring

Poor design:

Focus on functionality, while ignoring the real-life user

This presumes that dealing with all the bulleted items will avoid all possible bad outcomes. This thinking is just wrong. Inherent in a complex process is changing interactions between different people and the environment. Things evolve. Health care is no different. As a result, unexpected results can occur even if workers work with the utmost care and the processes have been designed to the utmost quality. Because things change around them.

This is more reason to take a more open view of error than that simply created by tired workers or inadequate processes. And to thrive with this open view requires a culture that does not work by "stored patterns of pre-programmed instructions," but that is mindful, aware, and welcomes observations and insights from anyone in the organization (not just doctors).

In addition to "Anatomy of an Error," Duke Medical Center would be well advised to teach their workers to be very aware of surprises and disappointments - to use a spy novel term, "expect the unexpected." If well-trained, well-rested staff perform a well-designed process and something still goes awry, that is not a defect, it is vital information. It means something has not been taken into account, that the environment has changed, and a cool, clearheaded review is in order. It could be the appearance of a new strain of resistant bacteria, a new designer drug, or simply a unique patient situation. The worst possible step is to hide the error or to engage in "quiet fixing."

This is the next level of training that groups like Duke need to embark on. They should be commended for training their staff on this weird topic of errors and mistakes. But they can't stop there; there's much left to do.

Duke Medical Center offers online training module "Anatomy of an Error"

@Whatsthepont pointed me to this online training module from Duke University Medical Center. Entitled "Anatomy of an Error," the course intends to teach hospital employees about the types of error they can expect and show them how to reduce error and avoid catastrophic outcomes through human factors and well-designed processes.

This is a very important piece of evidence that error and mistake awareness is becoming more prevalent in complex environments, such as health care, where it is badly needed. The Duke module is a good step forward. That being said, I have some criticisms of the course, which I will cover in a future post. For the moment, let's share the Duke definition of an error, which is aligned with the definition of a mistake from the introduction to the book:

Dr. James Reason, a Professor of Psychology who has published extensively on the nature of human error, describes error as circumstances in which planned actions fail to achieve the desired outcome.

Our definition of a mistake is: an unexpected result proceeding from faulty judgment or inadequate knowledge.

The Duke module is a very useful introduction to error and how it works in complex environments. But don't view it as the complete story - there are some significant missing components that I will discuss this week.

Paul Downs: you can't push workers for output and ask them to train at the same time

More from furniture maker Paul Downs, via the New York Times You're The Boss blog. This post resulted from his post on his reasons for and approach to firing people, and discusses mistakes he made during the economic downturn of the late '00's. Four years on, he has absorbed some pretty clear lessons from that time:

I’d like to address commenters who questioned my failure to train workers whom I had hired in the years before the crash in 2008. For instance, this comment:

Why would you fail to train people? Why would you not explain to the more experienced workers that training was worth more long term than output?

That’s a good question. And if, at that time, I had been able to focus on the long-term good of the company, I probably would have done things differently. However, that’s not where we were at that time.

We were hiring as fast as we could to complete some very large projects. At the same time, we were losing money hand over fist. The best way for us to raise cash was to complete the jobs we were working on. At that moment, output was much more important than training. I was putting a lot of pressure on my cadre of experienced workers to get jobs out the door — and at the same time dumping a crew of inexperienced warm bodies on them.

I told the old heads to train the new people, but I didn’t relieve anyone of their production responsibilities. And I didn’t put a single person in charge of training. Frankly, I was stupid, and I was setting up all of us for failure. Even at the time, I knew it wasn’t working, but I just couldn’t figure out what to do. It’s a lot easier to say “train people” than to think of actual ways to do it.

This article I wrote for The 99 Percent discusses the need for time to pass to draw deep lessons from mistakes.

"The first thing I did was take full responsibility for my predicament"

Another business mistake story reported by Marcia Pledger of The Cleveland Plain Dealer. This story is from Tony Kleem, owner of Tony K's Bar & Grille in Berea, Ohio.

The Mistake: My biggest mistake was opening a restaurant without doing enough research or surrounding myself with experienced employees. I had owned a small bar for several years, but running a restaurant with 160 seats is a whole different world.
I knew I needed to get into the food business in order to survive. But I spent more time planning menus then I did learning about operations. It doesn't matter how good the food is if your service is off.

In the nine months it took to build, I was focusing more on construction, furniture, equipment and hiring. The problem was I should have selected a manager with significant experience, including a restaurant opening. Except for learning the computerized ordering system, I didn't even offer training.

Looking back 12 years ago, I just closed my eyes and went through the wall. I didn't know basics, like having a soft opening on a Monday to work out the kinks. I opened on a Friday, and everything that could go wrong went wrong. Saturday was worse.

I comped a lot of meals that first weekend. You don't go into business to give away food and drinks. I did both, just trying to get customers to give my business a second chance. In the restaurant business, it's hard to get over bad first impressions.

The Fix: The first thing I did was take full responsibility for my predicament. Then I vowed to succeed, by doing whatever I could within reason to please customers.

Customers have to know that they're valued, and it's up to managers and the owner to make sure employees know that's the top priority. Sometimes it just means acknowledging an issue, then working to rectify it.

Communication is key. People don't mind waiting when you explain what's going on. I tell the staff that the customer is always right, even when they're not. If it's a situation that they can't handle, call in a manager to deal with it the proper way.

Soon after I opened, I spent the first two months cleaning house, making sure we had the right people in all sorts of positions.

To me, Tony's acknowledgement is key. "Taking responsibility for his predicament" allowed him to quickly see and understand his mistake. Rather than panicking, or blaming others, he owns up and figures out how to solve the situation. It is painful, and expensive, but he does it.

Contrast this with Tom Chaney of "True Grit." Despite being an outlaw and a killer, Chaney is the weakest person in the entire movie. He always moans about his predicament. "Everything is against me," he says, over and over again. All I can say is, I'm glad he never tried to open a restaurant.