There is a crucial yet hard-to-understand concept here. Most people grasp the need to set priorities; they put the biggest problems at the top, with smaller problems beneath them. There are simply too many small problems to consider them all. So they draw a horizontal line beneath which they will not tread, directing all their energies to those above the line. I believe there is another approach: If we allow more people to solve problems without permission, and if we tolerate (and don’t vilify) their mistakes, then we enable a much larger set of problems to be addressed. When a random problem pops up in this scenario, it causes no panic, because the threat of failure has been defanged. The individual or the organization responds with its best thinking, because the organization is not frozen, fearful, waiting for approval. Mistakes will still be made, but in my experience, they are fewer and farther between and are caught at an earlier stage.

Owning our errors becomes easier when we accept human fallibility as a fact and put that acceptance to use in learning and improving. In the most successful teams in my research, people, especially team leaders, talk about the ever-present chance that things will go wrong. They are honest and good-humored about mistakes, which nurtures the psychological safety you need for people to speak up quickly about them. This is a best practice—in families, too, not just work teams—if you want to reduce basic failures.

The problem with Perrow’s idea that organizations could not safely function with interactive complexity and tight coupling was that so many such organizations did in fact function without mishap for years, even decades. Nuclear power plants operated without incident nearly all the time. So did air traffic control systems, nuclear aircraft carriers, and a host of other inherently risky operations. A small group of researchers led by Karlene Roberts at the University of California, Berkeley, set out to study how they did it. What they discovered was more behavioral than technical. The term high reliability organization, or HRO, captures the essence of the theory. HROs are reliably safe because of how they make everyone in them feel accountable to one another for practices that consistently catch and correct

deviations to prevent major harm. Vigilance is one word for it. But it’s more than that. To me the most interesting part of HRO research is the observation that rather than downplaying failure, people in HROs are obsessed with failure. My colleagues Karl Weick, Kathie Sutcliffe, and David Obstfeld wrote a seminal paper highlighting the culture of HROs as preoccupied with failure, reluctant to simplify, acutely sensitive to ongoing operations (quick to detect subtle unexpected changes), committed to resilience (catching and correcting error,

rather than expecting error-free operations), and valuing expertise over rank. In other words, HROs are weird places. Rather than holding back to see what the boss is thinking, people there don’t hesitate to speak up immediately. A frontline associate, to avert a crisis, can tell the CEO what to do. Failure is clearly seen as an ever-present risk that can nonetheless be consistently averted.

“Use Systems Thinking to Change How We Think about Error …

Rely on inquiry

So Morath faced a challenge: How to help people to see and accept their hospital’s failures? Rather than doubling down on her logic—You work in a complex error-prone system, don’t you see? Things will go wrong!—she instead invited clinicians to reflect on their experiences that week with their patients, then prompted, “Was everything as safe as you would have liked it to have been?” Her aspirational question opened the floodgates. Most people had been in what Morath called “a health-care situation where something did not go well,” and

once they reflected on the many problems they had noticed, they became eager to talk about what had happened and how they might improve…

New language

Another element of the patient safety system was what Morath called Words to Work By—a roster of suggested terms designed to help shift mindsets from blaming to learning. Morath substituted neutral-sounding words such as study for the more threatening word investigation, which put people on the defensive…

Synergy…

As with the system at 3M that supported people’s intelligent failures in ways that encouraged product innovation, and the system at Toyota that made quality improvement second nature, Children’s Minnesota built a robust learning system that turned everyone into an active participant in patient safety. Morath’s approach reminds us that system design is more than simply coming into an organization and flipping a single switch. It’s flipping multiple switches understanding how they work as a system.

An organisation does things, and it systematically does some things rather than others. But that’s as far as it goes. Systems don’t make mistakes — if they do something, that’s their purpose. But it also works the other way around. Systems don’t have inner desires, so they don’t do things intentionally either. There’s just a network of cause and effect. We might think they’re conspiring, but they’re working within structures that made the outcome inevitable. Or we might see everything as a terrible cock-up, but we don’t understand that the outcome was the inevitable result of the way the system works.