Are Mistakes Systemic?
The more I deal with process design, the more I suspect human error is systemic. Not that we are flawless workers -- one author parses mistakes and slips by intention or outcome -- but we give the system a pass too often and blame human error. We work within complex systems, and our own techniques, memories, and attitudes are part of that system.
Given two baseball teams, for example, with equal talent, training, and experience, one may play much better. A manager in two different jobs may fail or succeed with the same style, approach, and agenda. And two laboratories may struggle or breeze through work with the same instruments, information system, and so on. In those cases where success is elusive, mistakes are often blamed for failure.
We should have played better. I should have disciplined the poor performers sooner. We need to work harder.
This seems logical if our experience tells us that all things being equal, human error is at fault. We all make mistakes, and we all think the solution to mistakes is working harder, paying more attention, goofing off less, developing better habits, or whatever we think will help. Good work habits are a hallmark of professionalism, sure. But should we beat ourselves up?
Think about the last mistake you made. What was your reaction? Did you think, “Wow, I really screwed up. I wasn’t paying attention and I need to work harder.” Or did you think, “How did that happen and can it happen to anyone else?” The former blames human error. The latter expands responsibility to the system.
Fact is if you’re an experienced tech who made a mistake regardless of your mood, state of mind, fatigue level, or distractions it’s likely that another experienced tech could do the same. We are all moody, tired, or not at the top of our game at times. There’s a line between blame and cause we aren’t willing to cross, because we think it can be perceived as avoiding personal responsibility for a mistake. But not crossing it or even acknowledging it isolates us from the system.
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