NSF Human error prevention training

Learning from Mistakes: The Surprising Truth About Success

NSF International, Pharma Biotech

What makes the difference between success and failure when the unexpected happens? For example, consider two examples of a train being late and over-crowded. In Case A, it was standing room only and bottled water and refreshments ran out quickly. Connections were missed and expensive taxi rides ensued. The train company’s complaints procedure was lacking and did not result in compensation or an apology, just excuses and denials. This company has since gone out of business. In Case B, the same situation of over-crowding and delays was mitigated by free refreshments, immediate reimbursement and a writtenapology. This business is thriving. The moral of the story?

Organizations that view learning from failure as a moral urgency will thrive. Those that don't, won't.

Matthew Syed (author of Black Box Thinking) makes a clever distinction between the winners and losers. “Openloop” companies (the winners) use problems as a source of innovation and improvement; as free lessons in what doesn't work. They forensically analyze what went wrong and make plans about what to do (differently) next time. Companies with “closed loops” don't do either. Errors are stigmatized, and sometimes hidden. People either deny failure or “spin” it to make it sound better. True causes are ignored and people, not systems, are blamed. Errors are considered an inconvenience to be side stepped to allow business to continue as usual. That is, until the train ride (their business) crashes.

Is Your Company Open Loop or Closed Loop? The Honesty Test

Take the 10 questions on the next page to your next team meeting and with your colleagues, answer them with a simple “yes” or “no” (5 minutes max). Make sure the debate that follows takes longer.

To set the scene before answering the questionnaire, reflect on the following:

  • In 2013 there were 36.4 million commercial flights carrying 3 billion passengers. Over this period, there was one death per 2.4 million flights.
  • This safety record is due to the aviation industry learning from mistakes in true open-loop style.
  • The healthcare sector is different. In the U.S. alone, between 44,000 and 98,000 patients die each year from preventable medical errors. That's the equivalent to two jumbo jets falling out of the sky every day. The number of deaths due to preventable and painful complications is even more astonishing. The UK's National Audit Office (2005) estimated that 34,000 deaths were due to “human error.”

The aviation industry learns from mistakes. Our healthcare sector clearly doesn't.

  • The cost of preventable errors in the pharmaceutical industry is massive. One leading pharma company estimated the cost to be € 300 million. How much longer can we continue to afford this waste?

The Honesty Test: Are You Open Loop or Closed Loop?

  1. Do you experience high levels of repeat deviations, problems or quality incidents?
  2. Do you apply the 30 day-rule to deviation investigations?
  3. Do your KPIs focus on reducing the total number of deviations?
  4. When a product fails to meet specification, do you start manufacture of the next batch before youhave completed a comprehensive investigation and fixed the cause(s), no matter how long theinvestigation takes?
  5. Do you focus on finding a single “root cause” of failures?
  6. Are most of your failures, problems and deviations attributed to human error?
  7. Is your deviation reporting SOP longer than 6 to 10 pages?
  8. Do most of your corrective actions focus on retraining and/or adding more detail to an SOP?
  9. Do you investigate every incident in the same way, irrespective of risk?
  10. Does your change control system approve every change request?

Any “yes” answers mean you have symptoms of a closed-loop culture. And you know what that means. Ask colleagues what it will take to move to a more open loop?

During our ‘Human Error Prevention’ workshop we discuss the practical steps needed to make this vital transition. It’s not that hard. (http://www.nsfhumanerrorprevention.org) 

Just remember, as Henry Ford once said:

“Failure is simply the opportunity to begin again, this time more intelligently.”

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