According to George Santayana Those who cannot remember the past are condemned to repeat it.
That can only mean that, unless we learn from our mistakes, we are apt to repeat them. Luckily. it has been found that similar mistakes have been made by very different people under very different circumstances. So we should take our mistakes to mean everybody's mistakes, not just our own mistakes. A study of past mistakes, has revealed that a relatively small group of factors have contributed to most of them - a fact that promises to make analysis simpler and more rewarding. A complication that cannot be avoided, however, is that it is very seldom that a single factor has been the sole cause of a mistake.
In view of the gains that might be expected from the analysis of past mistakes, it is surprising, that comparatively little effort has been devoted to the subject. Some important work is, however, being undertaken by health professionals. They have discovered a number of shortcomings of the present treatment of mistakes, the consequence of which has been that mistakes that could have been avoided are often repeated, imposing additional health service costs running into £billions. One of those shortcomings has been a tendency to conceal one's own mistakes and overlook those made by one's colleagues, fostered by a convention that it is best to find ways around the resulting difficulties and get on with the task in hand. Another has been a tendency to blame an individual and leave it at that - and so to overlook vital contributory factors.
The National Health Service has recently introduced a no-blame error reporting system and a retrospective review of each incident to identify what, how, and why it happened. Similar systems are in use by rail and airline operators. Other branches of government and industry are expected to follow suit. Major advances may be expected from the analysis of the information do collected
In the meantime there is a good deal to be learned from further study of the information already available.
The author of this blog has made a start on such a study in Mistakes, how they have happened and how some might be avoided (available from Amazon).
In view of the gains that might be expected from the analysis of past mistakes, it is surprising, that comparatively little effort has been devoted to the subject. Some important work is, however, being undertaken by health professionals. They have discovered a number of shortcomings of the present treatment of mistakes, the consequence of which has been that mistakes that could have been avoided are often repeated, imposing additional health service costs running into £billions. One of those shortcomings has been a tendency to conceal one's own mistakes and overlook those made by one's colleagues, fostered by a convention that it is best to find ways around the resulting difficulties and get on with the task in hand. Another has been a tendency to blame an individual and leave it at that - and so to overlook vital contributory factors.
The National Health Service has recently introduced a no-blame error reporting system and a retrospective review of each incident to identify what, how, and why it happened. Similar systems are in use by rail and airline operators. Other branches of government and industry are expected to follow suit. Major advances may be expected from the analysis of the information do collected
In the meantime there is a good deal to be learned from further study of the information already available.
The author of this blog has made a start on such a study in Mistakes, how they have happened and how some might be avoided (available from Amazon).
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