Fix the Problem, Not the Blame

Focus on "Why" not "What"

In Why We Make Mistakes, Joseph T. Hallinan argues that "When something goes wrong...the natural tendency is to lay blame. The misattribution of blame is one reason we make the same mistakes over and over again. We learn so little from experience because we blame the wrong cause. Knowing what happened alters our perception of why it happened."

I often find this with improvement teams. Team members come in with convictions about "what" is wrong and "why" it happened. By the time we've finished using the fishbone and five Whys, they are invariably proven wrong.

Hallinan sites many medical examples including anesthesiologists. The valves for two main types of anesthesia machines turned in opposite directions. The mistake-proofing fix involved standardizing the machines so that they both worked the same way.

The miss rate for radiologists hovers in the 30 percent range. Doctors at the Mayo clinic went back and checked the previous normal chest X-rays of patients who subsequently developed lung cancer. What they found was horrifying: up to 90 percent of the tumors were visible in the previous X-rays. The cancers were visible for months or even years.

Studies of autopsies have shown that doctors seriously misdiagnose fatal illnesses about 20 percent of the time. That's one out of five.

The rate of misdiagnosis has not really changed since the 1930s.

Overconfidence - The Leading Cause of Human Error

It helps, Hallinan says, to be less optimistic.

If an improvement team really understood the reasons why some problem occurred then they would have fixed the problem. Since the problem persists, the why still eludes them. I start by assuming they don't know what's really wrong or how to analyze it.


Hallinan recommends several strategies:

  • Think negatively - Before you act, ask yourself: "What could go wrong?" This is a simple form of Failure Modes and Effects Analysis (FMEA).
  • Multitasking is a Mirage - Slow down. The more things you try to do simultaneously, the greater the chance for error (e.g., driving while drinking coffee and talking on a cell phone and fiddling with the GPS.)
  • Get Some Sleep - Sleepy people make more mistakes.
  • Be Happy - "Happy people tend to be less prone to errors induced by habit."
  • Forget Incentives - Money does not affect average performance, but can degrade it."

Rights to reprint this article in company periodicals is freely given with the inclusion of the following tag line: "© 2012 Jay Arthur, the KnowWare® Man, (888) 468-1537,"

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