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A Better Idea Than Learning from Mistakes

Let’s Learn from the Mistakes that Almost Happened

Blog post by Gene Benson

Gene Benson is the Senior Human Factors Consultant for Bright Spot, Inc. He is the primary author and the program director of the "Being Better Program."

I spend a considerable amount of time in my error reduction programs analyzing the costly mistakes that have been made in a high-stakes industry. A single error often results in a multi-million-dollar cost to the company. I dig deep to find root causes of the errors and then I try to find a way to prevent a recurrence of the error. This approach is effective, mitigation strategies are usually easy, and we have seen dramatic reduction in the recurrence of same or similar errors. Unfortunately, the original error was made, significant costs were incurred by the company, and there is no way to turn the clock back to prevent the error.

Taking a page from my aviation background, there is a way to help us get in front of many costly errors and prevent them from occurring. Collecting data and studying the “near-misses” can be extremely effective. For every costly error that has happened, there are probably several instances of catching a problem and correcting it before it becomes a costly mistake.

In 1975, NASA introduced a program that is still very active and important today. Called the Aviation Safety and Reporting System (ASRS), pilots and other aviation professionals can file reports of narrowly avoided accidents, as well as unintentional violations of regulations and standard operating procedures. For their cooperation, they receive immunity from punitive measures. The individuals are asked to state what factors were involved and how the situation could have been avoided. The reports are made non-identifiable and analyzed for trends. Many thousands of reports have been filed and there is a robust database of valuable information available. Any interested party can access the vast database for the purposes of learning from the mistakes of others.

I believe there is a place for a similar system in high-stakes industries and I am presently getting a few in place. Analyzing the “near-misses” to prevent the costly error can only be done if we know about them. Employees are naturally reluctant to go to a supervisor and report that he or she became distracted by a text message and almost added an incorrect quantity of a reagent to a pharmaceutical drug batch. But if an anonymous report, guaranteeing no punitive action, could be filed to a third-party, we could be on a path toward seeing trends and mitigating the risk of having a costly error.

There are plenty of obstacles to initiating such a program. Employees are skeptical of the guarantee of both anonymity and immunity. Labor unions may oppose it unless some other concession is made. Stressed managers are reluctant to accept something that might increase their workload. Regulators might want to count reports as “deviations” that must be investigated. But all these obstacles can be overcome. The fastest and most effective way to initiate a program is to contract with a third-party service provider such as Bright Spot. We can help employees, union leaders, and regulators understand the purpose and operation of the program. We can also handle the data securely, ensuring anonymity. It can work and the results can be truly amazing as the database grows and new error reduction strategies become apparent.

If you would like to explore how we can help your company, contact me today.


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