Can Leadership Prevent Mistakes?

While I was in the middle of the room, the attic floor and beams collapsed onto the second floor crashing down to the first floor where I was standing. The time between us entering the building and the time of the collapse was no longer than 90 seconds. I was knocked to the floor and was trapped under the debris. I suffered a head injury and a torn patellar tendon. The contents of the upstairs ended up in the first floor room and I could have been killed. By my judgment, approximately 80,000 gallons of water was pumped into that structure and we were ordered in anyway. This was after a previous call to evacuate 45 minutes earlier. This should not have happened!

Mistakes happen. Sometimes, those mistakes hurt or kill people. I’ve studied them among fire fighters, who sometimes experience events like the one described above (which comes from Report 07-0001036, U.S. Department of Homeland Security, 2014). The mistakes that people in the fire service and other high-risk occupations make often have important safety implications. In other industries and occupations, mistakes may not hurt or kill people, but mistakes often derail projects or anger customers. They create conflict and they degrade the quality of what we make or do. 

Mistakes aren’t exclusive to any industry or sector. 

Mistakes also almost happen. These close calls or near misses—when discussed well and integrated into a learning program—can serve as powerful wakeup calls for people and teams.
Regardless of whether we’re talking about mistakes or near misses, learning from the past to improve future performance is a fundamental management and leadership objective (Catino & Patriotta, 2013; Morris & Moore, 2000). But a common problem that I’ve seen in organizations is that we’re often apt to treat mistakes as problems with individual people. Sometimes an individual person is part of the problem, but pinning a mistake on a single person doesn’t necessarily help a team or organization learn. Instead, what’s required is a culture that embraces learning from mistakes in non-judgmental, non-punitive way. 

One example of such an approach is in health care. Modern hospitals are systems in which extraordinary good and life-saving care happens daily. But they’re also places where mistakes hurt and even kill people. 

Frequently. 

And one person within the healthcare industry whose insights I’ve always enjoyed is Paul F. Levy, the former president and CEO of Beth Israel Deaconess Medical Center in Boston. 

In the clip below, he discusses some of the nuances of teamwork and leadership as they pertain to mistakes in health care. Paraphrasing one of his senior leaders commenting on what to do about a doctor who made a serious mistake (starting at 7:00 in the video), he says,

If we want to establish a culture in our organization that encourages and permits people to admit their mistakes and their near misses, we are more likely to establish that culture if we do not punish doctors who, with best of intentions, make a mistake. They’ve already suffered enough.

So, is there a way to make organizations error free? In this continually changing world, probably not. The key, instead, is to promote continual learning through what we do and what we say, catching small errors before they become big ones and taking the necessary steps to improve. That’s at the heart of building a team and organization that encourages open discussion of hazards and errors, of what almost went wrong and what could have happened. 

Years ago, I had a much more punitive approach to dealing with mistakes than I do now. That’s because I’ve realized that leadership isn’t about being perfect or having a perfect team. It’s about unlocking people’s own ability to learn, to imagine, and to become something greater than they realized was possible. 

Leadership, therefore, can’t prevent mistakes. But with an approach of humility, continuous improvement and open communication, it can help to build routines and patterns of learning that make mistakes less likely and less frequent. 

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About Ben Baran
Ben Baran, Ph.D., is probably one of the few people in the world who is equally comfortable in a university classroom, a corporate boardroom and in full body armor carrying a U.S. government-issued M4 assault rifle. More at www.benbaran.com and www.agilityconsulting.com.

References

Catino, M., G. Patriotta. 2013. Learning from errors: Cognition, emotions and safety culture in the Italian air force. Organizational Studies, 34: 437-467. 

Morris, M. W., P. C. Moore. 2000. The lessons we (don’t) learn: Counterfactual thinking and organizational accountability after a close call. Administrative Science Quarterly, 45: 737-765.

U.S. Department of Homeland Security. 2014. National Fire Fighter Near-Miss Reporting System. Retrieved from http://www.firefighternearmiss.com