We should not just try to stop things from going wrong.

Instead, we need to understand why most things go right, and then ensure that as much as possible indeed goes right.

So argues Sidney Dekker in his blog Safety Differently

The number of the things that go wrong is tiny. Their are a small number of things are the heroic, unexpected surprises (a Hudson River landing, for instance) that fall far outside what people would normally experience or have to deal with. In between, the huge bulbous middle, sits the quotidian or daily creation of success. This is where good outcomes are made, despite the organizational, operational and financial obstacles, despite the rules, the bureaucracy, the common frustrations and obstacles. This is where work can be hard, but is still successful. The way to make even further progress on safety is not by trying to make the red part of things that go wrong even smaller, but by understanding what accounts for the big middle part where things go right. And then enhancing the capacities that make it so.

Dekker and his team did some work for a Health Authority where 1 in 13 occasions of service resulted in a hurt to the patient.

The Health Authority had analysed these cases and found that common features included workarounds and shortcuts, procedures not being followed, with supervisory shortcomings.

The interpretation of this by the Health Authority was that

the person is the weakest link, … the ‘human factor’ is a set of mental and moral deficiencies that only great systems and stringent supervision can meaningfully guard against. In that sort of logic, we’ve got great systems and solid procedures—it’s just those people who are unreliable or non-compliant:

Dekker and his team chose to look at the 12 out of 13 cases that did not result in harm. They found that each of these showed workarounds and shortcuts and procedures not being followed with inadequate supervision. The exact same factors that were thought to cause harm were evident in the cases where the patient was safe.

The conclusion of the Health Authority had been that they needed more rules and guidelines and supervision and compliance.

Dekker and his team concluded that none of those solutions would make any difference to safety outcomes.

What does make a difference?

Dekker’s blog post outlines some suggestions and is an excellent read.

Pride of workmanship was certainly one key attribute of teams that produced more good results.

What can an organization do to support this? They can start by enabling their workers to do what they want to do and need to do, by removing unnecessary constraints and decluttering the bureaucracy surrounding their daily life on the job.

We have been advised to start every meeting with a story of a patient harm. Perhaps the only difference between cases where things go poorly and where they don’t is a matter of luck.

Perhaps in fact we need to begin with stories of where things have gone well – where a diagnosis was made, where a near miss was avoided, where a pathology result was followed up in difficult circumstances, where good communication occurred, where positive feedback was received,

Why Do Things Go Right – Sidney Dekker in Safety Differently