Only Two Ways To Look At Mistakes

According to James Reason, the former professor of Psychology at the University of Manchester, human fallibility is an inherent aspect of our existence. All people have potential to make mistakes, whether due to forgetfulness, inattention, or “moral weakness” (problematic phrase from the past that is better understood as a lack of impulse control), these are all undeniable parts of human behavior that we should accept without judgement.

In response to this reality, he outlined two distinct approaches that have emerged to tackle the problem of human fallibility: the person approach and the system approach. Each approach offers unique perspectives and strategies for addressing human errors in various contexts.

The Person Approach: The person approach places the primary responsibility for errors on individuals themselves. It assumes that human errors stem from personal shortcomings, such as lack of knowledge, inattentiveness, or moral failures. In this view, individuals are seen as the weak links in the system, and the emphasis is on identifying and correcting their deficiencies. Some key characteristics of the person approach include:

1. Blaming individuals: When an error occurs, this approach often leads to blaming the person responsible for the mistake. It may result in disciplinary actions, reprimands, or even termination in cases of severe consequences.
2. Training and education: Organizations using the person approach often invest heavily in training and education programs to enhance individuals’ skills and knowledge. The assumption is that better-trained individuals will make fewer errors.
3. Individual accountability: Accountability is a central concept in the person approach. Individuals are expected to take full responsibility for their actions and errors, creating a culture of fear and reluctance to report mistakes.
4. Limited systemic change: The person approach tends to focus on addressing errors at the individual level without considering broader systemic factors that may contribute to errors.

The System Approach: In contrast, the system approach acknowledges that human errors often occur within a larger context and are influenced by the conditions and environment in which individuals work. It recognizes that individuals are fallible and that errors are an inevitable part of complex systems. Key features of the system approach include:

1. Focusing on the system: This approach shifts the focus from individual blame to examining the conditions and processes within the system that may contribute to errors. It seeks to understand why errors happen rather than who is to blame.
2. Building defenses: Instead of solely relying on the perfection of individuals, the system approach seeks to build defenses within the system to prevent errors or mitigate their consequences. This includes creating redundancy, safety checks, and fail-safes.
3. Encouraging reporting: A critical aspect of the system approach is the promotion of open and honest reporting of errors. It recognizes that individuals are more likely to report mistakes if they do not fear punitive consequences.
4. Continuous improvement: Organizations adopting the system approach are committed to ongoing learning and improvement. They use data and feedback to identify weaknesses in the system and make necessary changes to reduce the likelihood of errors.

James Reason’s contributions to studying human error and risk management includes the Swiss Cheese Model which posits that accidents only happen when multiple barriers fail.

High-Reliability Organizations (HROs): High-reliability organizations (HROs) are entities that operate in environments where the consequences of errors can be catastrophic, such as nuclear power plants, aviation, and healthcare. HROs recognize that human fallibility is an ever-present risk, but they take a unique approach to managing it. HROs understand that human variability can be harnessed as a resource rather than viewed solely as a liability. They do so by:

1. Focusing on reliability: HROs place an unwavering emphasis on the reliability of their systems and processes. They are constantly preoccupied with the possibility of failure and work diligently to minimize risks.
2. Encouraging resilience: HROs foster a culture of resilience and adaptability, encouraging individuals to respond effectively to unexpected challenges and errors when they occur.
3. Emphasizing teamwork: Teamwork and effective communication are critical in HROs. They recognize that collaboration among individuals can act as a defense against errors.
4. Learning from errors: HROs see errors as opportunities for learning and improvement. They conduct thorough investigations to understand the root causes of errors and make systemic changes to prevent recurrence.

The person approach and the system approach represent two distinct ways of addressing human fallibility. While the person approach tends to place blame on individuals and focus on their deficiencies, the system approach recognizes that errors are often the result of complex systemic factors. High-reliability organizations take the system approach to a higher level by harnessing human variability and constantly striving to minimize the potential for errors.