By Frantz Belot, Ph.D.
Fostering a Learning Organization is the Antidote
Human error is often misinterpreted as solely a human issue. However, it predominantly arises from system flaws within organizations. We inadvertently create systems that tolerate poor processes for the sake of rewarding outcomes, leading to constraints and errors. Understanding this dynamic is crucial to prevent and mitigate human error.
The fact is that human error is a multifaceted issue that is misunderstood. It is easy and tempting to attribute errors solely to individual shortcomings, but the reality is that human error is intricately linked to the systems we create within organizations. These systems inadvertently tolerate flawed processes in the pursuit of desired outcomes, leading to constraints and, ultimately, errors. To effectively prevent and mitigate human error, it is crucial to shift our focus towards understanding the systemic factors at play. To do this effectively, we must explore the complex relationship between human error and systems, and discover strategies to promote safety and foster a learning culture, and still achieve optimal business outcomes.
The Complexity of Human Error and Root Causes
Traditionally, human error has been labeled as the root cause of incidents and accidents. However, experts argue that this perspective oversimplifies the issue. According to Outcome Engenuity, human error is often a symptom of deeper systemic failures. Human error should be viewed as a result of flawed organizational systems rather than an isolated failing of individuals. When organizations solely focus on blaming individuals, they miss the opportunity to address the underlying causes and prevent future errors.
In the groundbreaking book, The Field Guide to Understanding ‘Human Error’ author Sydney Dekker says it is crucial to see human error as a symptom of deeper issues and ask what is really responsible for the outcome. This should be used as a starting point of investigation and prevention.
TapRooT, an incident investigation and root cause analysis company, suggests that errors occur due to a variety of factors, including inadequate training, unclear procedures, inadequate supervision, ineffective communication, and more. Identifying these contributing factors allows organizations to implement targeted interventions and system improvements to reduce the likelihood of errors and accidents.
Redefining Human Error with Systemic Analysis
To gain a deeper understanding of human error, it is crucial to redefine our perception of it. Safety Stratus, a safety consulting firm, argues that labeling human error as a cause is misleading and counterproductive. They emphasize that human error is a meaningless term on its own, as it fails to provide meaningful insights into the underlying factors that contribute to errors. Instead, they advocate for a shift towards a systems approach, focusing on understanding the organizational conditions and processes that lead to errors.
Adopting a systemic analysis approach allows organizations to delve deeper into the factors that influence human behavior and contribute to errors. This analysis involves examining the organizational culture, leadership practices, communication channels, training programs, and work processes. By thoroughly understanding these elements, organizations can identify potential weaknesses in their systems and make targeted improvements to prevent errors.
In Behind Human Error, Dekker argues that people do things that make sense to them at the time given other constraints and priorities. Investigation should ask why employees thought they were doing the right thing or why their actions made sense to them at the time.
For example, “Having a large safety bureaucracy could actually increase the probability of an accident. A bureaucracy can produce “fantasy documents” and demand compliance with cumbersome processes while not dealing with real sources of risk.”
Creating a Learning Organization With Effective Training Programs
Building a learning organization is a key aspect of addressing human error and promoting safety. A learning organization encourages a proactive approach to safety, where employees are empowered to improve their skills and knowledge continuously. It fosters a culture of open communication, where reporting errors and near-misses is encouraged without fear of blame or punishment. This enables organizations to learn from incidents and implement preventive measures.
One of the pillars of a learning organization is the implementation of effective training programs. Organizations can utilize video-based microlearning courses to provide employees with accessible and engaging learning experiences. These courses offer short, focused content that can be easily understood and retained. By delivering training in bite-sized formats, organizations can ensure that employees have the knowledge and skills necessary to navigate complex systems and make informed decisions that prioritize safety.
Microlearning is a powerful tool that can greatly contribute to addressing human error and promoting a learning culture within organizations. It involves the delivery of small, focused units of learning content that can be consumed quickly and conveniently. Microlearning courses are designed to be easily accessible to employees at their convenience, allowing for learning during short breaks or downtime.
Another powerful advantage of microlearning is the ability for employees to create and transfer their best practices to the organization. Imagine a workforce that is empowered to share their best practices and to communicate them to their peers. That is the ultimate expression of a learning organization.
The bite-sized nature of microlearning modules ensures that employees can engage with the content and retain the information effectively. These modules can be accessed whenever employees encounter specific tasks or situations, promoting just-in-time learning and reducing errors caused by knowledge gaps.
Additionally, the interactive and multimedia elements in microlearning courses enhance engagement and knowledge retention. Continuous access to microlearning modules fosters a culture of continuous learning and progress tracking, empowering employees to actively participate in their professional growth and contribute to a positive learning culture. Microlearning facilitates employees content creation and transfer of their best practices to the organization. Imagine a workforce that is empowered to share their best practices and to communicate them to their peers. That is the ultimate expression of a learning organization.
The Power of a Learning Culture
A learning culture is a catalyst for organizational growth and improvement. It encourages employees to embrace a mindset of continuous learning and development, which in turn leads to better decision-making, increased efficiency, and reduced human error. In a learning culture, as stated above, employees are empowered to share knowledge, learn from mistakes, and actively contribute to the improvement of systems and processes. This collaborative and innovative environment nurtures engagement, motivation, and a sense of ownership among employees, ultimately creating a safer and more productive workplace.
Learning cultures thrive on continuous improvement and feedback loops. Organizations should establish mechanisms for employees to provide feedback, report concerns, and suggest improvements. This feedback loop enables organizations to identify system weaknesses and implement corrective actions promptly. By actively involving employees in the improvement process, organizations empower them to take ownership of safety and contribute to the prevention of errors and accidents.
A strong learning culture also builds a safety culture that not only protects employees from harm but also enhances productivity, reduces costs associated with incidents, and improves overall organizational performance.
By understanding that human error is a symptom of flawed systems, organizations can proactively identify and address system weaknesses to promote safety. This approach shifts the focus from blame to continuous improvement and fosters a sense of accountability and shared responsibility for safety throughout the organization.
Conclusion
Human error is a complex issue deeply intertwined with organizational systems. Recognizing that human error is a symptom of systemic failures rather than a root cause is crucial in preventing and mitigating errors. By adopting a systemic analysis approach, organizations can identify the underlying factors contributing to errors and make targeted improvements.
Building a learning organization that prioritizes continuous improvement and fosters a culture of safety is essential. By implementing effective training programs, promoting open communication, and establishing feedback loops, organizations can empower their workforce, reduce human error, and create a safer and more productive workplace. Let’s embrace a systemic perspective, unlock the potential of our systems, and cultivate a learning culture that prioritizes safety and optimal outcomes.
To learn more about building a learning culture, please schedule an appointment to speak with a Tyfoom training consultant.