As you will learn in this book, how we frame or reframe failure has a great deal to do with our capacity to fail well. Reframing failure is the life-enhancing skill that helps us overcome our spontaneous aversion to failure. It starts with the willingness to look at yourself—not to engage in extensive self-criticism or to enumerate your personal flaws, but to become more aware of universal tendencies that stem from how we’re wired and are compounded by how we’re socialized. This is not about rumination—a repetitive negative thought process that isn’t productive—or self-flagellation. But it may mean taking a look at some of your idiosyncratic habits. Without this, it’s hard to experiment with practices that help us think and act differently.

Embracing the Possibility of Failure to Reduce the Occurrence of Failure

My decades-long fascination with error, harm, and failure has left me humble about the complexity of these topics. The mix of factors—technology, psychology, management, systems—means none of us can master every aspect of the relevant knowledge to feel “we’ve got this.” But a few simple practices have emerged from my work that can help prevent complex failures. With these, we all have the power to make that kind of difference—in our own lives and in the organizations we care about.

Experts in almost any field take context into account habitually. The rest of us have to remind ourselves to do it. To practice situation awareness is to appreciate where you are right now, so you can adopt the right mindset for the context and the stakes. Perhaps you can think of a time at work when you tormented yourself with anxiety about whether you would succeed in a role or a project. I know I can. It happened many times while I was writing this book! Situation awareness allows you to take stock of where you are and proceed appropriately, sometimes to reduce unhelpful anxiety and other times to lower risk. It’s about developing the habit to pause and check—both for in-the-moment reactions and when planning some project or event—by asking yourself two essential questions: Where am I on the context spectrum? And what’s at stake?

Chapter Seven: Appreciating Systems

“In addition to organizational systems such as 3M, all of us operate in systems in our everyday lives—family systems, ecosystems, and school systems, to name a few. This makes system awareness—especially understanding how systems can produce unwanted failures—a crucial skill in the science of failing well. A system’s results are less shaped by its individual parts than by how the parts relate to one another. This simple but powerful idea can help you analyze and design various systems in your life to get better results. Later in this chapter I’ll return to how 3M designed a system to generate the right kind of wrong and thereby spawn countless innovations. But first, let’s take a closer look at what it means to think in terms of systems.

“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.