What a Real Preoccupation With Failure Could Look Like

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The Joint Commission is guiding health systems toward becoming high-reliability organizations (HRO), similar to oil and gas, naval aviation, and nuclear power industries. These industries perform with a remarkable degree of safety, despite working in dynamic and hazardous conditions.
This degree of safety performance is no accident. Two researchers studied HROs and found repeatable practices that helped ensure safety.1 These organizations function under 2 sociocultural conditions. Organization leaders profoundly respect all employees, and all employees want to learn and improve safety and operations. They also operationalize 2 logics: (1) anticipate mistakes because all systems are fallible and standardize work when feasible to prevent mistakes and (2) recover from mistakes, building resiliency into daily work.
HROs know they must manage error effectively, or they will spend all their time responding to errors. Thus, they create mindful organizing structures in which they constantly envision what could go wrong and design systems to defend against and recover from mishaps. Although this preoccupation with failure is a tenet of HRO, it is often overlooked in health care.
Health care workers often assume things will go right rather than wrong. This is understandable because clinicians choose health care to help people–-to fulfill a sense of altruism. Such optimism that all is well poses significant risk to patient safety. To defend against risk, regulatory organizations such as The Joint Commission require that health care organizations conduct a proactive risk assessment at least every 18 months after a new or changing process.
Although well intended, an 18-month stretch for risk assessments is hardly a preoccupation with failure. Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job. Being mindful does not mean thinking longer or harder, it involves thinking about and seeing risks and behaving to improve safety. The same sense of altruism can move every level of a health care organization to practice this preoccupation with failure every day–-make it a habit.
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