Managing Human Error
by Ramon Rivera
In organizations, errors have double implications. On the one hand, there is no doubt that errors can contribute to grave consequences. On the other hand, most people readily agree that one can learn from errors. On the one hand, organizations want to do ‘the things they do’ without errors. They want to exploit the methods that have proven their success, and improve them. This implies preventing, controlling and auditing known processes, and focusing on reliability and stability. On the other hand, organizations want to be adaptable and innovative and explore new ideas and methods. In this respect, errors provide organizations with learning opportunities. Both goals of control and learning are valid and important. It is, however, difficult for organizations to find an optimal balance between the two.
A mere focus on exploration leaves an organization with many new ideas lacking necessary refinement. A mere focus on exploitation is likely to leave the organization with well-developed, but sub-optimal methods. The two approaches require conflicting strategies (e.g. auditing versus risk taking and experimentation), which make it hard to achieve an optimal balance. Yet, in order to keep competitive advantage, organizations need both reliability and stability associated with control, as well as adaptability and innovativeness associated with learning.
A commonly used approach for avoiding negative error consequences is preventing the error itself. Error prevention implies a focus on the goal of control. Error prevention does not necessarily allow learning. Organizational learning strategies such as experimentation are in direct conflict with error prevention’s goal of control: Errors are needed for learning from them.
A more intelligent approach to error management is distinguishing between errors and their consequences. While error prevention aims at avoiding negative error consequences by avoiding the error altogether, the error management approach should focus on error consequences directly. The aim is the avoidance of negative error consequences and the promotion of positive error consequences by means of early error detection, quick and effective correction, error analysis, and long term learning from errors. Error management is a strategy well suited for supporting both goals of control and learning.
Intelligent error management overcomes the inherent conflict in allocating resources between the two. Both goals of control (avoiding negative error consequences) and learning (promoting positive error consequences) are embedded in the approach. Negative error consequences can be avoided without avoiding the error itself (goal of control), at the time positive error consequences can be promoted (goal of learning).
Intelligent error management is directly supported by a mastery orientation towards errors. That is, as an orientation toward developing ability, taking failure as a challenge to be mastered, generating effective strategies and maintaining effective striving under failure. Mastery orientation as an aspect of error culture is similarly focused at overcoming difficulties associated with errors, and developing better strategies for the future. It entails that members of the organization communicate about errors, analyze errors’ causes, deal with errors actively (i.e. quick and effective recovery), and attempt to learn from errors.
Our research reveals that highly performing teams tend to report more errors (i.e. make more errors and/or are more willing to report them). That happens when teams operate in a better error climate, which allows them to talk about errors, which in turn increases detection and correction. Such climates allow teams to make a distinction between an error (i.e. wrong medication order) and its negative consequence (i.e. harming a patient). Further, the open climate, characterized by a willingness to report and discuss errors, allows learning from errors, and thereby can affect team performance positively.
Given that human error will never disappear from organizational life, an important management issue thus becomes the design and nurture of work environments in which it is possible to learn from mistakes and to collectively avoid making the same ones in the future. Based on research in high reliability organizations, we have found that high reliability organizations tend to reward the reporting of errors, and focus on organizational (i.e. shared) responsibility rather than on blaming the direct actor. The organization as a whole, not a single actor, should be the object under investigation. Similarly, we propose that an error management approach be studied in terms of organizational culture dimensions.
Anticipation of errors and knowledge, acceptance and anticipation of risks relate to a general awareness of errors. In calculated risk taking the organization accepts that it is sometimes necessary and useful to risk an error. Anticipation of errors is important because it aids the detection of errors. Only errors that are detected can be managed well. Error awareness thus relates to a preparedness for the unexpected, a continuous anticipation of future surprises. In sum, error awareness increases the likelihood of early error detection and prepares the organization for error handling. As such, error awareness indirectly supports error management.
Strain and covering up reflect a negative attitude towards errors, or error aversion. In organizations where employees are punished for their mistakes, employees are likely to experience strain, and may decide to cover up their errors. Strain and covering up diminish communication, analysis, correction, and learning, and thus, indirectly, hinder error management. Errors that are covered up remain undetected (a least to those who did not cover them up), and therefore run the risk of accumulating negative consequences. This effect can be explained from the viewpoint of focused attention: when errors are considered to be threatening, attention (i.e. cognitive resources) is directed to the self, rather than the task (Kluger & DeNisi, 1996). Translated to the domain at hand, error strain takes away resources needed for error handling.
Error management culture should be a matter of high concern for managers as it is an issue of high conceptual importance for studies on organizational change and organizational learning. Errors will appear whenever companies reduce the number of routines people can rely on. People will more likely participate actively in change processes if their errors are not punished. When companies attempt to be superior to other companies we would advise them to focus on a culture that fosters the open discussion of errors, the analysis and efficient correction of errors, and learning from errors.
Managers should realize that errors are not always avoidable and errors should therefore be tolerated to a certain degree. This does not mean that they should not be taken seriously. As a matter of fact, we suggest that errors should be taken more seriously than is often done. While errors traditionally are discussed only when the consequences are high or even disastrous, we suggest that errors with small consequences should also be taken as chances to learn. Organizations should be encouraged to take responsibility for their errors. Error management culture is an important, and up to this point unexplored, element for many if not most companies to gain competitive advantage.