How to learn from Making a Big Mistake

According to research by Amy C. Edmondson, Olivia Jung, and their colleagues, exposure to disasters can lead to meaningful innovation, but only if employees are psychologically safe to contemplate direct encounters there.

What if companies could learn from their worst mistakes without making them? How can similar advances and innovations take place without companies bearing the costs associated with such failures? Findings from a recent study of near misses in healthcare show that near misses occur when people feel safe speaking in the workplace. A neighborhood will emerge that will stimulate growth and significantly improve the system.

Amy C. Edmondson, a Harvard Business School professor who studies psychological safety and organizational learning, says, “People don’t pay enough attention to the potential bonanza of near misses, especially in the business world. Incidents that lead to near misses or damage. often go undetected, partly because workers fear being associated with vulnerability or failure. However, when leaders present near misses as a free learning opportunity and teach their teams the value of resilience, it increases employees’ ability to report such incidents Increase.

This is the key conclusion of Resilience in the Face of Vulnerability: Psychological Safety and the Reporting of Different Near-Dead Errors in Radiation Oncology, a study co-authored by Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, and Olivia Jung, a student, did her doctorate at HBS. Co-authors of the paper, published in the Joint Committee Journal on Patient Safety and Quality, include UCLA physicians Palak Kundu, John Hegde, Michael Steinberg and Ann Raldow, and medical physicist Nzhde Agazayan.

The research team wanted to understand the role of psychological safety, defined as “the shared belief that it is safe to take risks among individuals,” in determining the likelihood of radiation oncology professionals reporting near misses, and whether this is the case varies depending on the nature of the incident.

We almost made a big mistake,’ said Jung. “This interpretation highlights a gap in the nursing process. But it can also be counted as a success if one says: ‘We recognized the mistake and provided an excellent service‘, which shows the resilience of the care systems. To shed some light on this complexity, the team interviewed 78 radiation oncologists at the University of California, Los Angeles, first asking the group about their perceptions of the psychological safety in the department.

Overall, they found that people felt responsible for each other and were comfortable talking, but there were significant differences by role, with high-level staff such as doctors often feeling it was safer to talk than lower-level staff such as nurses and – nursing therapists. It’s a finding that’s consistent across many studies of psychological safety and device safety across industries.

Edmondson says. “People of higher status often feel that their voices are welcome,” she says. Next, investigators developed a series of reality-based what-if scenarios. For example, doctors should screen cancer patients undergoing radiation therapy for pacemakers, which may fail during treatment. Staff were asked to rate the likelihood of reporting the following near misses, which became increasingly threatening to the patient. This could have happened. The patient’s pacemaker status was not verified at the initial consultation.

Fortunately, the patient did not have a pacemaker and received radiation therapy with no further harm. Caught by accident. Pacemaker status has not been checked. The patient had a pacemaker, but by chance a member of the team noticed this and the patient’s treatment was postponed until he was discharged. It’s almost there. Pacemaker status has not been checked. The patient was fitted with a pacemaker and received radiation therapy, but coincidentally the patient had no complications.

When compared to the results of the first survey, the data shows that the more likely it is that a situation will cause harm to the patient, the more important psychological safety becomes in deciding whether staff should report a near miss.

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