Imagine this scenario.  Bob, a good employee, messed up a transaction/job/task/project.  It was an honest mistake.  Those happen to people in every job title, at every level and in every industry.  From chefs to cashiers and from deliverymen to doctors, people make mistakes.  It is why they put erasers on pencils.  But, this particular mistake affected customers and coworkers, and created a safety hazard.  (When doctors and pharmacists make mistakes, those can even put people’s lives at risk.)  Mistakes happen but those mistakes can also have serious repercussions.  Now what?

Before you say “my department (or company or organization) seldom makes mistakes”, don’t bother.  The fictional scenario above actually plays out in every enterprise, every day.  Any leader who thinks there is such a thing as an error-free day needs to look more carefully and see the blunders on the wall.  Big or small, mistakes are plentiful.  In fact, Dr. David J. Smith created Human Error Rate Tables for his Reliability Engineering course textbook titled ‘Reliability, Maintainability and Risk’.  The table looked at the average human failure rates across industries collected during the latter-half of 20th century.  The table showed that errors abound.  According to Smith, “Human Error Rate Tables confirm that ‘human element’ and ‘human factor’ error is real and unavoidable. We do not perform well when tasks require great care, and we perform especially badly under complicated non-routine conditions. Add stress into that that mix and you get disaster.”[1]

He went on to say, “From the research and studies done by the aircraft industry on ‘human factors’ and the ‘human element,’ it is clear that people are the greatest remaining cause of failure by far.  The problems that exist with any given company are not plant, equipment or machine problems.  The equipment and machines are fine. Their engineering, the materials-of-construction of their parts and their manufacturing methods are fine. The problems of poor equipment reliability, poor maintenance results and poor production performance are almost entirely due to human errors that happen throughout companies—from entry level employees to Boardroom execs.”[2]

These same error rates are present in the medical field with complicated tasks such as surgeries.  In Complications:  A Surgeon’s Notes on an Imperfect Science Dr. Atul Gawande writes, “A Harvard Medical Practice Study – a review of more than 30,000 hospital admissions in New York – found that nearly 4% of hospital patients suffered complications from treatment which either prolonged their hospital stay or resulted in disability or death, and 2/3 of such complications were due to errors in care.  One in four – or 1% of all admissions – involved actual negligence.  It was estimated that, nationwide, upward of 44,000 patients die each year at least partly as a result of errors in care.”[3] He also noted that in another study “of how clinicians perform when patients have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator – charging it incorrectly or losing too much time trying to figure out how to work a particular model.”  That is an error rate of 90%.  The worst part is that the errors don’t fall to just a small group of “bad doctors.”  Gawande indicated that “Most surgeons are sued at least once in the course of their careers…. Virtually everyone (every single person) who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year.”  Errors are ubiquitous.

While the mistakes that most people commit at work don’t involve life and death situations, they could potentially be costly to a company.  How managers handle employee mistakes (and their own) has a big impact not only in the outcome of that specific situation, but also in how many more mistakes are made.  It can affect how creative and productive that employee will be thereafter.  It could also have a huge impact on customer retention, if an internal or external customer was impacted.  And, it can have a profound impact on employee turnover not only with that employee, but also with others on the team.  All of these factors have a profound effect on the bottom line.  Yes, mistakes happen, but how the situation is handled can make things better or worse.  It is not enough to understand “what happened?” after an error but to decide “what happens next”.

Dealing with Errors

First, an organization’s culture influences how a leader deals with mistakes.  In a learning culture that values improvement, a company’s leadership is open to employees making mistakes and see it as a part of the company’s growth and improvement process.  But, in a command-and-control culture, there is much less tolerance and mistakes are derided and vilified.  For example, how would a restaurant manager deal with an employee who just dropped an entire tray of dishes and stemware?  In a learning culture, the server might be asked what caused him to drop the tray.  A slippery/wet floor might prompt the manager to purchase mats for certain areas and require employees to wear shoes with rubber, non-slip soles.  But in a command-and-control culture, the employee might be made to “pay” for the broken dishes from his next paycheck or lose his job if it happens too frequently.  For companies that want to reduce mistakes and the fallout from those errors, a learning culture is better.  Here’s how it should work.

1. Give Time.

Before inquiring about any mistake or mishap, the supervisor must first ensure that the crisis is over and the problem is resolved.   Whether hurricane or hiccup, during a problem is neither the time nor place to address mistakes.  Everyone involved should be given time to sort things out and rectify the situation.

2. Acknowledge that Mistakes Happen.

Because a mistake always puts an employee on the defensive, it is important for the supervisor to disarm the conversation.  One of Edward Deming’s 14 key principles for managers was to eliminate fear in the workplace.  The Deming Institute indicates “Drive out fear so that everyone may work effectively for the company.”[4] What matters is the employee’s intent, not outcome.  Most employees don’t relish failing and don’t want to make mistakes.  They don’t err on purpose.  Moreover, employees learn and grow when they feel safe to report their mistakes to a manager. Employees should be encouraged to report their mistakes and find ways to correct and prevent them.  After all, Albert Einstein once said, “A person who never made a mistake never tried anything new.”

3. Ask Questions.  Then Listen.

How the leader corrects mistakes can impact the degree of employees’ fear and their level of concern when they make an error.  How a leader reacts in trying to improve performance or results or to get an employee on track with a defined process, rule or policy is key to making things better. Consider if the mistake should be swept under the rug (not every error needs to be addressed), aired out (improvements cannot be made if there is no willingness to recognize a recurring problem) or if there is another option.  Is there a way to point out a mistake without demoralizing the employee and/or undermining his performance and creativity down the road?

If it is something that needs to be addressed, the supervisor should ask the employee key questions.  Determine exactly what happened.  Ask those directly involved; not a third-party or someone with an agenda or axe to grind.  Does the mistake happen often?  How often?  Did the mistake affect an internal or external customer?  How was the issue handled by the employee?  What did the employee’s immediate supervisor do or say?  Is there anything more that should have been or can still be done to rectify the problem?   These questions should be asked slowly, calmly and gently.  One question at a time; not like machine-gun fire.  After each question, the employee should be allowed to answer.  The supervisor needs to listen – really listen carefully – to the answers.  No one should feel like he/she is being confronted or under attack.   The goal, after all, should be to understand, rectify and improve, not punish.

Use the Mistake as an Opportunity to Improve.

Another important question to ask:  can anything be done to keep the mistake from happening again?   According to the Human Error Rate Table created by Dr. David J. Smith, we see that “Starting at the bottom of the human error table, the error rate increases as it moves upward.

Complicated non-routine tasks                        1 error in 10

Routine tasks with care needed                       1 error in 100

Routine simple task                                        1 error in 1000

Simplest possible task                                    1 error in 10,000

What causes it to move up?  Complexity.  Lack of routine.  Lack of time.  Stress.  External factors.  Clearly, whatever can be done to simplify a task and remove complication will deliver sure reductions in human failure rates.”  For example, if there is a job that requires a review of tasks before the job is completed, the error rate (of not catching a mistake) was found to be as high as 1 in 10.  However, for ‘Wrongly carrying out a visual inspection for a defined criterion (i.e. Left in a sponge in the patient, left clamp in the patient, left instrument in the patient)’ the error rate falls to 3 in 1,000.  Why?  If people use checklists with specific criteria to check, instead of remembering what to do, a person who goes down a list is much less likely to make a mistake or overlook something.  Intentionally designing the process to have a checklist results in 100 times fewer errors and costs almost nothing to implement. That is a simple solution any business can implement for negligible cost.  Look for simple solutions and implement processes and systems that reduce the potential for errors.

Most mistakes require nothing more than a conversation.

Most mistakes provide an opportunity to teach. But, it should not be assumed that the employee knows or understands the issue that needs correcting.  The supervisor should ask the questions required to confirm whether the employee has the knowledge, skills and attitude to avoid repeating the mistake. The goal of a simple conversation is to ensure the employee is clear, has the knowledge, skills and attitude to proceed, and has a go-forward plan to not repeat the mistake.

When companies address mistakes in a positive way, they are able to retain customers and employees and reduce the likelihood of the same mistake happening again and again.  That is what turns a mistake into an opportunity.

Quote of the Week

“You make mistakes.  Mistakes don’t make you.” Maxwell Maltz

© 2019, Keren Peters-Atkinson. All rights reserved.