News January – Black Box Thinking · Matthey Syed

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Learning from mistakes

We begin our 2017 news with this book, which surprised us by the clarity of examples used, the rotundity of its arguments, and the adequacy of its central message: Either we learn from our errors and failures, in an honest, open and disciplined manner, or all progress is halted.

It takes the two very different professions of aviation and medicine to provide a response to the core question: Where do these professions obtain the learning to support their evolution?

We all know that a major source of learning is contained in our setbacks, errors and failures. Syed tells us how aviation has developed mechanisms and processes to learn from accidents, and pass the lessons on to the industry throughout the world. Hence its extraordinary evolution in the area of safety.

However, within the medical profession, despite huge scientific and technological advances, learning from errors in the application of these advances is not so systemized. In fact, we see how errors in diagnosis are covered up. As it says: “In 2013 a study published in the Journal of Patient Safety put the number of premature deaths associated with preventable harm at more than 400,000 per year. (…) What these numbers say is that every day, a 747, two of them are chasing. Every two months, 9-11 is occurring. (…) These figures place preventable medical error in hospitals as the third biggest killer in the United States – behind only heart disease and cancer.” Incredible, but supported by the data!

If we cannot systemize learning through errors, it becomes hugely difficult for us to stimulate innovation in our fields, and take advantage of its benefits.

How have you systemized learning through errors in your organization? Without doubt, this is a huge point for improvement in the majority of organizations.

This is how it begins…

On 29 March 2005, Martin Bromiley woke up at 6.15 a.m. and made his way to the bedrooms of his two young children. It was a rainy spring morning, a few days after Eastern and the kids were in high sprinted downstairs for breakfast. A few minutes later, they were joined by Elaine, their mum, who had snatched a few extra minutes in bed.

Elaine, a vivacious thirty-seven-year-old who had worked in the travel industry before becoming a full-time mother, had a big day ahead: she was due in hospital. She had been suffering from sinus problems for a couple of years and had been advised that it would be sensible to have an operation to deal with the issue once and for all. ‘Don’t worry’, the doctor had told her. ‘The risks are tiny. It is a routine operation.’


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