Safety is important in every industry, but how organisations think they achieve it is quite different. We see organisations in all kinds of sectors, from healthcare to industry and from laboratories to the food industry. And how they deal with safety varies considerably.
This is partly understandable: the consequences of a mistake made in healthcare or in an office are also quite different. And the standards and guidelines, laws and regulations for industries are also quite diverse. In addition, it is not in the nature of many people to ask others how they do it, you quickly feel burdened to ask for someone else’s time, and then even selflessly.
A shame, if you ask us. Because organisations can learn so much from each other. From how safety is looked at and how mistakes, incidents and blames are handled. Every organisation has best practices in this. So that peek by the neighbours? Just do it! What you can learn from them, we will be happy to tell you.
Let’s start with healthcare. A mistake there can have very big consequences. We all know the stories of wrong medication or a mistake made during an operation and especially what it means for the victims. People’s lives are literally at stake here.
So it is not surprising that strict controls apply here. And that there is a disciplinary board that independently assesses whether the mistake could have been prevented. In doing so, it is not uncommon to point the finger; making the question of guilt personal is quite normal here. And ultimately, these lessons learned are meant to take the organisation to a point where fewer incidents happen. Except that those lessons are learned the hard way.
However, this also creates a culture where there is little psychological safety. Indeed, this requires the ability to report mistakes and incidents without being personally blamed. From a ‘Blame’ culture to ‘Just Culture‘. You don’t get that easily, and certainly not if you work in an industry where personal blame still weighs heavily.
Yet in this respect, healthcare could learn a lot from others. For instance, from best practices in the industry.
When something goes wrong in an industry, they are less and less likely to look for the culprit. So does that mean they don’t report and analyse incidents? Certainly not! In fact, by not asking for blame, the willingness to report an incident goes up. We can illustrate this with an example:
Suppose you work in the automotive industry and during production you use a wrong screw. This comes up during an inspection and is fixed before the car goes to its new owner. So nothing else serious has happened.
The person who conducted the check made a report that a wrong screw was used. Then it is easy to say that is your fault. Within Just Culture, however, we look beyond the human factor. After all, what is the reason you used that very screw? Was it in the wrong container? Was it delivered incorrectly? Were the work instructions not clear?
If the cause is clear, the process can be adjusted so that this mistake cannot be made again, and there is no one pointing a finger at you.
And now suppose that the error is not noticed and the new owner of the car has a serious accident as a result. That does not change the incident analysis process, which looks the same. Unless intent is involved, you will not be held responsible. That makes no one feel burdened to report an incident.
That is quite a difference from a nurse administering the wrong medicine because they were not prepared properly. The nurse is expected to check, and when things still go wrong, he or she is responsible. And that while the outcome of the accident above may be even more serious than that of the wrongly administered medicine. You can probably imagine that the willingness to report these kinds of mistakes is not that great. It does happen, but it will probably be reluctant.
You might also wonder how these two ways of dealing with incidents affect an organisation’s or department’s lessons learned. In a culture where there is less finger-pointing of blame, people may well be more open to learning from others.
Looking at laboratories, the pharmaceutical and chemical industries, we see that these organisations often suffer from regulatory pressure. They have to comply with many laws and standards, follow various guidelines and record it all. What these organisations often have in common is that they have a culture where everyone is responsible for safety. We don’t need to tell them much about integrated risk management: managing risks is in their DNA.
Everyone knows the big picture, is familiar with the organisation’s goals and knows how his or her work contributes to them. In turn, this is at odds with how a care worker often thinks: he or she went into care to take care of others. Rules and administration are then only seen as a burden. Employees from the aforementioned industries understand better that this is part of the job. Seeing the bigger picture is something care workers can learn from them.
On the other hand, almost every commercial company can also learn something from healthcare institutions. Namely that setting a goal like 0 accidents or 0 incidents does not contribute to safety. Especially if the difference between the current situation and the target is large. The goal then becomes a target in itself.
In healthcare, they are often more realistic in this respect: reduce the number of incidents on an annual basis by 10%, for example. That is manageable and will scare people less. These are best practices that organisations from different industries can learn from each other.
This will increase the willingness to report, because then a report does not immediately mean that the target can no longer be met. And then the reports can be used again for the organisation’s lessons learned.
What matters no matter what industry you work in is for the fact that you want to have insight into and overview of what is happening within your organisation. For that, reporting incidents is key. Instructing that everything must be reported on pain of something (suspension, dismissal) certainly does not contribute to the willingness to report. That does not achieve psychological safety. And so it does not contribute to the process of lessons learned either.
If you want to work on this structurally, the conditions have to be right. To this end, it may be useful to take a look behind the scenes of an organisation to see how they approach this successfully and what their best practices are. Don’t know where to start? On the Infoland Community, around 1,500 members share a lot of knowledge with each other. To learn from each other. This includes members who work within an organisation where they have a Just Culture custom and they are surely willing to help you.
At user days, you have the chance to speak to other users in real life, from which new insights can emerge. You will see that you don’t always have to reinvent the wheel if you talk to each other. In doing so, especially look beyond the borders of your industry for fresh new insights and their lessons learned.
Our Zenya software can also contribute to greater security within your organisation. The Capture App makes reporting possible for everyone, anytime and anywhere. The reports can be investigated for the cause with the powerful incident analyses such as Root Cause or 5 Why, without assigning blame. This allows you to extract lessons learned from this, which increases safety.
In addition, the Webshare option in Zenya DOC offers the possibility to exchange documents, from work instructions to process descriptions, with other organisations. This allows you to almost literally take a look in each other’s kitchen and makes learning from each other even easier.
And what about literally walking in on your neighbours and asking how they do things? What their best practices and lessons learned are? You will see that many people will be happy to think along with you and share their tips. And who knows, maybe you can inspire someone else with your approach!
Are you curious about how smart software contributes to psychological safety and a lessons learned process? Our experts will be happy to share best practices from different industries with you!