Magazine article Ivey Business Journal Online

Mistakes Happen - So Manage Them

Magazine article Ivey Business Journal Online

Mistakes Happen - So Manage Them

Article excerpt

There is typically a paradox whenever an organization deals with errors. On the one hand, because mistakes are bound to happen, senior management needs to encourage error reporting and related learnings by cultivating a constructive perspective. On the other hand, it is equally important for an organization - especially a high-reliability one such as a nuclear power plant or airline - to attempt to avoid mistakes by calling for responsible conduct and reminding employees of the importance of minimizing or eliminating errors in task execution. The resolution of this paradox calls for a combination of error prevention and error management. This can appear difficult. After all, while error prevention typically views all errors as unacceptable, error management emphasizes constructive responses such as learning from errors based on error acceptance.

This article offers insights into employees' perceptions and tacit norms around honest mistakes and recommends strategies and actions that managers can adopt to help organizations deal with the mistake paradox.

Not all errors are created equal or viewed the same way. As Sidney Dekker, an expert studying system failure and human error, pointed out in Just Culture: Balancing Safety and Accountability, people tend to view wilful violations as unacceptable, while honest mistakes are seen as acceptable. As a result, in order to build a just and accountable error management culture, it is imperative for managers and organizations to bring clarity to what is forgivable and what is not while also facilitating error reporting among employees. But to do this effectively, organizational leaders must first understand employees' tacit norms and perceptions of what constitutes an honest mistake.

For this paper, we interviewed 19 North American pharmacists and technicians (12 staffpharmacists and seven pharmacy technicians) from 10 different community pharmacies to help us understand what employees perceive to be "honest mistakes" and why. Using our findings, we recommend specific actions that managers and organizations can take to encourage reporting and learning from honest mistakes at all levels within the organization.

DEFINING HONEST MISTAKES

Examining the data, we found that almost all interviewees admitted or witnessed medication errors made at work, and examples of honest mistakes offered by the interviewees range from delivering the wrong medicine/dose and giving medicine to the wrong patient to failing to provide proper instructions. We independently examined the interview transcripts, and four categories of errors were identified and are listed below (see Table 1).

1. CHANCE OCCURRENCES: Mistakes that are attributed to unfortunate probability or bad luck.

2. ACTION OF OTHERS: Most mistakes, at least in pharmacies, involve multiple people. This category of mistakes refers to those that originate primarily because of someone else's actions.

3. ATTENTION DEFICIT: Mistakes caused by a lack of attention due to situational factors (e.g., workload strain, time pressure, new staff, or brand new processes/issues).

4. WELL-INTENTIONED MISTAKES: Mistakes that employees committed out of a good purpose (e.g., meant for customers' convenience, but deviated from standard processes without checking with doctors/patients first).

The first three identified types of honest mistakes were described by interviewees as unintentional errors involving no intent to harm. Only the final category of mistake involves purposeful, if misguided, action on the part of the person committing the error.

Honest mistakes, when reported, present valuable opportunities for organizational learning and better control of errors through the examination of contributing factors and processes. But managers must adjust their approach to dealing with honest mistakes based on their root causes. Our data revealed that key sources of honest mistakes range from individual actions and choices (e. …

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