What types of mistakes do you make?

“We cannot change the human condition, but we can change the conditions under which humans work”

-James Reason

When you have a disability or you are raising a child with one, you face unique challenges. These conditions very often conflict with how society is designed. It is this friction where the problems start. Many days it feels like you are just moving from problem to problem. The problems overtake your life but you do your best. You get mad at yourself for all the mistakes you make. The right decisions just move on, while the mistakes are painful and linger for a long time. And you only remember the mistakes! Why is the brain setup this way?

Reality, to be human is to make mistakes. Most people understand this. Yet as a society we don’t really believe this because if we did, we would be more compassionate to the mistakes people make. We like to blame people, it’s almost a human need. Whenever there is a plane crash, we want to know what the pilots did wrong. A teacher or parent makes a mistake, it must be their fault. Our world is complicated, yet human condition drives us to simplify things. And very often this over simplification causes us to place blame on individuals, very often incorrectly. We need a scapegoat.

In a paper written by James Reason, professor of psychology at the University of Manchester, he goes into the different types of human errors. In his view there are two types. The first is the person approach. As the name suggests, this is where mistakes are caused by the individual. The traditional view of the person approach focuses on the mistaken behaviors (errors and procedural violations) of people at the sharp end: nurses, doctors, teachers, therapist, parents to name a few. It views these mistakes as arising primarily from mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Believers of this approach tend to treat mistakes or errors as moral issues. They assume that bad things happen to bad, overwhelmed or incompetent people.

The second view is from a systems approach. In this view humans make errors and are fallible. And rather than being surprised when a mistake occurs, it should be expected and looked at from a more holistic view. In this view errors are seen as consequences rather than the cause. It is the environment or “the system” factors that is the origin of the negative event. And the way you address these errors is by looking at the system rather than the individual. Humans are very difficult to change, especially long term, but systems can be changed. The system approach relies on system defenses to fight against errors. New technologies (this includes new processes, mindset etc.) can be implemented to create safeguards. When mistakes happen the most important issue is not focused on the individuals but how and why these defenses failed.

Evaluating the person approach

In Reason’s paper he acknowledges that the person approach is the most common way we view errors but it is deeply flawed.

He states:

“Blaming individuals is emotionally more satisfying than targeting institutions. People are viewed as free agents capable of choosing between safe and unsafe modes of behaviour. If something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible. Seeking as far as possible to uncouple a person’s unsafe acts from any institutional responsibility is clearly in the interests of managers.”

From a human condition perspective blaming others feels like the right thing to do. Yet he gives an example in an aviation maintenance study where almost 90% of quality lapses were judged as blameless. Blaming people for things they can not control seems wrong, but we do it everyday and very often to ourselves. Placing blame in the wrong area reduces you and/or the organization’s the ability to learn and get better.

He suggests the following to start the process of correctly identifying the root of the problem:

“Effective risk management depends crucially on establishing a reporting culture.3 Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.”

Getting information on each situation is critical for learning how to reduce errors. Without this information the same mistakes and errors will be repeated.

In the paper he talks about Chernobyl and how the complete absence of a reporting culture within the Soviet Union played a huge part in the disaster. The workers and engineers knew there were issues but were too scared to report their concerns. They felt that reporting would only get them in trouble. There was no trust in the system, so they remained silent until it was too late.

The only way a person and/or an organization can learn is if high quality and accurate information is brought back into the system. In order to get this feedback there needs to be a culture in place that encourages the reporting of these mistakes.

Creating this feedback loop is hard but is critical to creating a lasting and supportive community.

“Trust is a key element of a reporting culture and this, in turn, requires the existence of a just culture — one possessing a collective understanding of where the line should be drawn between blameless and blameworthy actions.5 Engineering a just culture is an essential early step in creating a safe culture.”

A person needs to feel safe in order to talk about their mistakes. They can not be looked down upon or even worse punished for revealing their flaws and mistakes.

Another flaw in the person approach:

“Another serious weakness of the person approach is that by focusing on the individual origins of error it isolates unsafe acts from their system context. As a result, two important features of human error tend to be overlooked. Firstly, it is often the best people who make the worst mistakes — error is not the monopoly of an unfortunate few. Secondly, far from being random, mishaps tend to fall into recurrent patterns. The same set of circumstances can provoke similar errors, regardless of the people involved. The pursuit of greater safety is seriously impeded by an approach that does not seek out and remove the error provoking properties within the system at large.”

In summary for most situations blaming others does not solve the problem, it just buries it and places the responsibility and resulting consequences on the individual. And the same mistakes continue to be made.

Society and the disability community

In the disability community it is my opinion that far too many of the mistakes are looked at thru this person approach. This makes sense. If society overall makes this mistake why would we be different. But as a community and the additional challenges we face, the consequence of these types of mistakes just amplifies the pain and hides potential solutions.

Now I am not an absolutist on this. There is personal accountability, no doubt, but as a society I feel like there needs to be a more balanced approach to the struggles people with disabilities and their caregivers face. It is too easy and in many ways comforting to blame the individual.

Society is much better than it was say 50 years ago but there is still work to do. So maybe the next time you hear or read a story where a mistake was made, you pause for a second and think about the system or situation this person or organization faces. Is there another origin of this mistake? Very often there will be. It just takes a little thinking, a different perspective and compassion to find it. It’s only when we identify and correct the true cause of mistakes will the system (i.e. society) get better.