How can we learn from human error? | Ivan Pupulidy, PhD | TEDxABQSalon

for more than ten years the

for more than ten years the third-largest cause of death in the

third-largest cause of death in the

third-largest cause of death in the United States has been attributed to

United States has been attributed to

United States has been attributed to preventable medical error the numbers

preventable medical error the numbers

preventable medical error the numbers associated with this are 300 thousand to

associated with this are 300 thousand to

associated with this are 300 thousand to four hundred and forty thousand

four hundred and forty thousand

four hundred and forty thousand fatalities per year it’s a shocking

fatalities per year it’s a shocking

fatalities per year it’s a shocking number it’s a lot and it’s increasing so

number it’s a lot and it’s increasing so

number it’s a lot and it’s increasing so we should think about this number and we

we should think about this number and we

we should think about this number and we should look at it very carefully our

should look at it very carefully our

should look at it very carefully our safety specialists have spawned what

safety specialists have spawned what

safety specialists have spawned what they call the Global War on error and

they call the Global War on error and

they call the Global War on error and out of this have emerged two fundamental

out of this have emerged two fundamental

out of this have emerged two fundamental pathways the first pathway is mechanical

pathways the first pathway is mechanical

pathways the first pathway is mechanical or mechanistic it’s putting

or mechanistic it’s putting

or mechanistic it’s putting interventions or interlocks in place and

interventions or interlocks in place and

interventions or interlocks in place and you’re probably familiar with many of

you’re probably familiar with many of

you’re probably familiar with many of these these are the things that keep us

these these are the things that keep us

these these are the things that keep us from making mistakes and these are

from making mistakes and these are

from making mistakes and these are upstream management efforts pre-emptive

upstream management efforts pre-emptive

upstream management efforts pre-emptive and for the most part they’re very

and for the most part they’re very

and for the most part they’re very effective but there’s another side the

effective but there’s another side the

effective but there’s another side the second side looks at the human aspect

second side looks at the human aspect

second side looks at the human aspect the human contribution and what happens

the human contribution and what happens

the human contribution and what happens with humans when humans make mistakes

with humans when humans make mistakes

with humans when humans make mistakes well sadly our current methodologies are

well sadly our current methodologies are

well sadly our current methodologies are pretty much dedicated to trying to

pretty much dedicated to trying to

pretty much dedicated to trying to ascribe blame or error as causal and

ascribe blame or error as causal and

ascribe blame or error as causal and what happens in this is we end up making

what happens in this is we end up making

what happens in this is we end up making actions determining them or judging them

actions determining them or judging them

actions determining them or judging them to be good or bad and at the same time

to be good or bad and at the same time

to be good or bad and at the same time judging people as being good or bad the

judging people as being good or bad the

judging people as being good or bad the problem here is that that doesn’t trap

problem here is that that doesn’t trap

problem here is that that doesn’t trap error that traps people so what I’d like

error that traps people so what I’d like

error that traps people so what I’d like to do now is I’d like to explore who we

to do now is I’d like to explore who we

to do now is I’d like to explore who we are who our error makers what are we

are who our error makers what are we

are who our error makers what are we raise your hand if you’ve ever made a

raise your hand if you’ve ever made a

raise your hand if you’ve ever made a mistake look around the room keep your

mistake look around the room keep your

mistake look around the room keep your hand up if you’ve made one today

hand up if you’ve made one today

hand up if you’ve made one today so it’s kind of like Shakespeare said he

so it’s kind of like Shakespeare said he

so it’s kind of like Shakespeare said he said to err is human and we’re all part

said to err is human and we’re all part

said to err is human and we’re all part of the human club so if we’re going to

of the human club so if we’re going to

of the human club so if we’re going to think about systems and we’re going to

think about systems and we’re going to

think about systems and we’re going to say that a system has to be error-free

say that a system has to be error-free

say that a system has to be error-free guess what I can guarantee that that

guess what I can guarantee that that

guess what I can guarantee that that system will fail but let’s think about

system will fail but let’s think about

system will fail but let’s think about this another way let’s think about how

this another way let’s think about how

this another way let’s think about how people have to work inside of a gray

people have to work inside of a gray

people have to work inside of a gray area that things aren’t really black and

area that things aren’t really black and

area that things aren’t really black and white right and wrong in most workplaces

white right and wrong in most workplaces

white right and wrong in most workplaces in fact most workplaces are complex and

in fact most workplaces are complex and

in fact most workplaces are complex and the world and mother nature have a

the world and mother nature have a

the world and mother nature have a tendency to hold their secrets close and

tendency to hold their secrets close and

tendency to hold their secrets close and let them out sometimes at the worst

let them out sometimes at the worst

let them out sometimes at the worst possible time let me give you an example

possible time let me give you an example

possible time let me give you an example of how some some of these complexities

of how some some of these complexities

of how some some of these complexities appear in normal work Chicago O’Hare

appear in normal work Chicago O’Hare

appear in normal work Chicago O’Hare Airport sports this sign keep off red

Airport sports this sign keep off red

Airport sports this sign keep off red line which I’d be really happy to do if

line which I’d be really happy to do if

line which I’d be really happy to do if I could find the red line how about this

I could find the red line how about this

I could find the red line how about this regulation I mean here’s a roll it

regulation I mean here’s a roll it

regulation I mean here’s a roll it clearly in conflict with another rule

clearly in conflict with another rule

clearly in conflict with another rule one of my most favorites though is this

one of my most favorites though is this

one of my most favorites though is this how we Brett respectively after the

how we Brett respectively after the

how we Brett respectively after the error has occurred try to hold people

error has occurred try to hold people

error has occurred try to hold people accountable even in the worst possible

accountable even in the worst possible

accountable even in the worst possible circumstances

yeah so as we start thinking about who

yeah so as we start thinking about who we are as human beings we have to start

we are as human beings we have to start

we are as human beings we have to start thinking about what the intention of our

thinking about what the intention of our

thinking about what the intention of our people are so we hire people how many

people are so we hire people how many

people are so we hire people how many people raise your hand if you’ve hired

people raise your hand if you’ve hired

people raise your hand if you’ve hired somebody okay most of the time when you

somebody okay most of the time when you

somebody okay most of the time when you hire somebody or your work colleagues

hire somebody or your work colleagues

hire somebody or your work colleagues you look upon them as being good people

you look upon them as being good people

you look upon them as being good people and they are good people and guess what

and they are good people and guess what

and they are good people and guess what when they have an error or make a

when they have an error or make a

when they have an error or make a mistake they’re still good people

mistake they’re still good people

mistake they’re still good people they’re still well intended good people

they’re still well intended good people

they’re still well intended good people you call yourselves caregivers most of

you call yourselves caregivers most of

you call yourselves caregivers most of you have taken an oath to that effect so

you have taken an oath to that effect so

you have taken an oath to that effect so we should think about who these people

we should think about who these people

we should think about who these people are

are

are let’s explore this this worker intends

let’s explore this this worker intends

let’s explore this this worker intends to do the best that she can okay

to do the best that she can okay

to do the best that she can okay now for full clarity this person is

now for full clarity this person is

now for full clarity this person is standing with one foot on a ladder

standing with one foot on a ladder

standing with one foot on a ladder another foot on a door that is not

another foot on a door that is not

another foot on a door that is not secured and she’s painting over her head

secured and she’s painting over her head

secured and she’s painting over her head to make sure that she gets paint on the

to make sure that she gets paint on the

to make sure that she gets paint on the wall and not on the ceiling how does

wall and not on the ceiling how does

wall and not on the ceiling how does this worker describe success at the end

this worker describe success at the end

this worker describe success at the end of the day no paint on the ceiling

of the day no paint on the ceiling

of the day no paint on the ceiling exactly right so success is this but

exactly right so success is this but

exactly right so success is this but failure do you think the person thinks

failure do you think the person thinks

failure do you think the person thinks that failure is falling in the stairwell

that failure is falling in the stairwell

that failure is falling in the stairwell well I can tell you from personal

well I can tell you from personal

well I can tell you from personal experience because this happens to be my

experience because this happens to be my

experience because this happens to be my wife

but she did not think that this was a

but she did not think that this was a risky maneuver and she was doing the

risky maneuver and she was doing the

risky maneuver and she was doing the best she could with what she had and I

best she could with what she had and I

best she could with what she had and I bet every one of you has been in a

bet every one of you has been in a

bet every one of you has been in a situation that is similar to this

situation that is similar to this

situation that is similar to this and none of you got the Darwin order you

and none of you got the Darwin order you

and none of you got the Darwin order you wouldn’t be here and if you did if

wouldn’t be here and if you did if

wouldn’t be here and if you did if somebody did ascribe something like that

somebody did ascribe something like that

somebody did ascribe something like that something as terrible as the Darwin

something as terrible as the Darwin

something as terrible as the Darwin Award how would it make you feel inside

Award how would it make you feel inside

Award how would it make you feel inside what would it take away from you and

what would it take away from you and

what would it take away from you and this is what we’ve done with our current

this is what we’ve done with our current

this is what we’ve done with our current processes of accident investigation now

processes of accident investigation now

processes of accident investigation now I’ve been doing accident investigation

I’ve been doing accident investigation

I’ve been doing accident investigation for over 20 years I’ve seen a lot they

for over 20 years I’ve seen a lot they

for over 20 years I’ve seen a lot they usually call me when there’s a fatality

usually call me when there’s a fatality

usually call me when there’s a fatality and what I’ve got to tell you is this

and what I’ve got to tell you is this

and what I’ve got to tell you is this that our approach has been fundamentally

that our approach has been fundamentally

that our approach has been fundamentally dispositional what I mean by that is

dispositional what I mean by that is

dispositional what I mean by that is we’ve looked at the disposition of

we’ve looked at the disposition of

we’ve looked at the disposition of people we’ve tried to say that they were

people we’ve tried to say that they were

people we’ve tried to say that they were bad people and sometimes that makes us

bad people and sometimes that makes us

bad people and sometimes that makes us feel good afterwards because gosh knows

feel good afterwards because gosh knows

feel good afterwards because gosh knows I’m not a bad person

I’m not a bad person

I’m not a bad person so what happens when they are successful

so what happens when they are successful

so what happens when they are successful with an innovation the opposite is true

with an innovation the opposite is true

with an innovation the opposite is true if they’re successful with the

if they’re successful with the

if they’re successful with the innovation and my wife doesn’t get paint

innovation and my wife doesn’t get paint

innovation and my wife doesn’t get paint on the ceiling and it all ends up on the

on the ceiling and it all ends up on the

on the ceiling and it all ends up on the wall then we say you were thinking

wall then we say you were thinking

wall then we say you were thinking outside the box and we reward that but

outside the box and we reward that but

outside the box and we reward that but it’s the same adaptation so the same

it’s the same adaptation so the same

it’s the same adaptation so the same adaptations that result in success

adaptations that result in success

adaptations that result in success result in failure so what I’m suggesting

result in failure so what I’m suggesting

result in failure so what I’m suggesting is this dispositional idea of judgment

is this dispositional idea of judgment

is this dispositional idea of judgment doesn’t really move us toward learning

doesn’t really move us toward learning

doesn’t really move us toward learning and the real currency that we have in

and the real currency that we have in

and the real currency that we have in safety to improve safety in any

safety to improve safety in any

safety to improve safety in any workplace is information and if we cut

workplace is information and if we cut

workplace is information and if we cut that conduit of information off if we

that conduit of information off if we

that conduit of information off if we ostracize people and make them feel bad

ostracize people and make them feel bad

ostracize people and make them feel bad we’re going to lose that source of

we’re going to lose that source of

we’re going to lose that source of information so what we’ve done is we’ve

information so what we’ve done is we’ve

information so what we’ve done is we’ve looked at this a very different way and

looked at this a very different way and

looked at this a very different way and my research has shown that what we need

my research has shown that what we need

my research has shown that what we need to do is focus on the conditions that

to do is focus on the conditions that

to do is focus on the conditions that influence decisions and actions we have

influence decisions and actions we have

influence decisions and actions we have to ask a question that is more

to ask a question that is more

to ask a question that is more situational in nature than dispositional

situational in nature than dispositional

situational in nature than dispositional and that question is pretty simple why

and that question is pretty simple why

and that question is pretty simple why did it make sense for good people to do

did it make sense for good people to do

did it make sense for good people to do what they did and in order to understand

what they did and in order to understand

what they did and in order to understand that

that

that we’ve got to look at the conditions that

we’ve got to look at the conditions that

we’ve got to look at the conditions that supported decisions and actions we

supported decisions and actions we

supported decisions and actions we create a thing that we call a network of

create a thing that we call a network of

create a thing that we call a network of influences map and we call it a network

influences map and we call it a network

influences map and we call it a network because we see these things these

because we see these things these

because we see these things these conditions as nested and networked and

conditions as nested and networked and

conditions as nested and networked and influencing each other as well as

influencing each other as well as

influencing each other as well as influencing the individual we’ve all

influencing the individual we’ve all

influencing the individual we’ve all seen it

seen it

seen it sometimes we’re influenced for the

sometimes we’re influenced for the

sometimes we’re influenced for the better sometimes we take less risk for

better sometimes we take less risk for

better sometimes we take less risk for example sometimes we’re influenced to

example sometimes we’re influenced to

example sometimes we’re influenced to take more risk and that’s not

take more risk and that’s not

take more risk and that’s not necessarily for the worse sometimes we

necessarily for the worse sometimes we

necessarily for the worse sometimes we have to take risk because there is no

have to take risk because there is no

have to take risk because there is no zero risk option and that’s another

zero risk option and that’s another

zero risk option and that’s another thing that we’ve got to understand that

thing that we’ve got to understand that

thing that we’ve got to understand that lives in this gray area so this is just

lives in this gray area so this is just

lives in this gray area so this is just one example from one of the accidents

one example from one of the accidents

one example from one of the accidents that we did and just to give you an idea

that we did and just to give you an idea

that we did and just to give you an idea what this grows into it grows into

what this grows into it grows into

what this grows into it grows into something like that and I don’t expect

something like that and I don’t expect

something like that and I don’t expect you to read that for what I do expect

you to read that for what I do expect

you to read that for what I do expect you to do is understand that the

you to do is understand that the

you to do is understand that the conditions are really really extremely

conditions are really really extremely

conditions are really really extremely diffused within our system and they’re

diffused within our system and they’re

diffused within our system and they’re very rarely depicted in a way that

very rarely depicted in a way that

very rarely depicted in a way that leadership can understand much less that

leadership can understand much less that

leadership can understand much less that the field can understand so out of this

the field can understand so out of this

the field can understand so out of this process what we expect is this we expect

process what we expect is this we expect

process what we expect is this we expect that our leaders who are really imbued

that our leaders who are really imbued

that our leaders who are really imbued with one responsibility and that is to

with one responsibility and that is to

with one responsibility and that is to create a workplace wherein workers can

create a workplace wherein workers can

create a workplace wherein workers can be safe wherein workers can be

be safe wherein workers can be

be safe wherein workers can be successful our leaders are imbued with

successful our leaders are imbued with

successful our leaders are imbued with that responsibility when we think about

that responsibility when we think about

that responsibility when we think about a safety function in our organization

a safety function in our organization

a safety function in our organization our responsibility as safety managers is

our responsibility as safety managers is

our responsibility as safety managers is to deliver information to that

to deliver information to that

to deliver information to that leadership so that they can make

leadership so that they can make

leadership so that they can make informed decisions if they’re aware of

informed decisions if they’re aware of

informed decisions if they’re aware of the conditions in the workplace that

the conditions in the workplace that

the conditions in the workplace that make error more likely they’re going to

make error more likely they’re going to

make error more likely they’re going to be able to address the conditions

be able to address the conditions

be able to address the conditions instead of creating second victims by

instead of creating second victims by

instead of creating second victims by admonishing the workers and that’s the

admonishing the workers and that’s the

admonishing the workers and that’s the goal so what do we say about this we

goal so what do we say about this we

goal so what do we say about this we look at it like this I hate to divide

look at it like this I hate to divide

look at it like this I hate to divide things in binary opposites but sadly

things in binary opposites but sadly

things in binary opposites but sadly this process of accident review has been

this process of accident review has been

this process of accident review has been forced into this place if we stay on the

forced into this place if we stay on the

forced into this place if we stay on the side of judgments

side of judgments

side of judgments we end up infusing pain distrust and

we end up infusing pain distrust and

we end up infusing pain distrust and silence emerges in our system but if on

silence emerges in our system but if on

silence emerges in our system but if on the other hand our focus is learning and

the other hand our focus is learning and

the other hand our focus is learning and the questions that we ask move to that

the questions that we ask move to that

the questions that we ask move to that learning place the difference is

learning place the difference is

learning place the difference is profound because then we have trust we

profound because then we have trust we

profound because then we have trust we have sharing of information and the

have sharing of information and the

have sharing of information and the system is richer for it now as I

system is richer for it now as I

system is richer for it now as I mentioned I’ve done accident

mentioned I’ve done accident

mentioned I’ve done accident investigation for 20 years and I bet

investigation for 20 years and I bet

investigation for 20 years and I bet some of you are thinking what about

some of you are thinking what about

some of you are thinking what about accountability well I can say this about

accountability well I can say this about

accountability well I can say this about accountability organizations after an

accountability organizations after an

accountability organizations after an accident are accountable to learn as

accident are accountable to learn as

accident are accountable to learn as much as they can to prevent the next

much as they can to prevent the next

much as they can to prevent the next accident but let me share one more thing

accident but let me share one more thing

accident but let me share one more thing with you I’ve done a lot of interviews

with you I’ve done a lot of interviews

with you I’ve done a lot of interviews in those last 20 years hundreds if not

in those last 20 years hundreds if not

in those last 20 years hundreds if not more well hundreds at least and in those

more well hundreds at least and in those

more well hundreds at least and in those interviews I can tell you one thing

interviews I can tell you one thing

interviews I can tell you one thing about the people that I’ve interviewed

about the people that I’ve interviewed

about the people that I’ve interviewed there is no way that any system can hold

there is no way that any system can hold

there is no way that any system can hold them more accountable than they hold

them more accountable than they hold

them more accountable than they hold themselves

themselves

themselves [Applause]