Description
Book SynopsisThe first comprehensive reference work on error management, blending the latest thinking with state of the art industry practice on how organizations can learn from mistakes.
Even today the reality of error management in some organizations is simple: “Don’t make mistakes. And if you do, you’re on your own unless you can blame someone else.” In most, it has moved on but it is still often centered around quality control, with Six Sigma Black Belts seeking to eradicate errors with an unattainable goal of zero.
But the best organizations have gone further. They understand that mistakes happen, be they systemic or human. They have realized that rather than being stigmatized, errors have to be openly discussed, analyzed, and used as a source for learning.
In How Could This Happen? Jan Hagen collects insights from the leading academics in this field – covering the prerequisites for error reporting, such as psychological safety, organizational learning and innovation, safety management systems, and the influence of senior leadership behavior on the reporting climate.
This research is complemented by contributions from practitioners who write about their professional experiences of error management. They provide not only ideas for implementation but also offer an inside view of highly demanding work environments, such as flight operations in the military and operating nuclear submarines.
Every organization makes mistakes. Not every organization learns from them. It’s the job of leaders to create the culture and processes that enable that to happen. Hagen and his team show you how.
Table of Contents1 Zhike Lei Fast, Slow, and Pause: Understanding Error Management via a Temporal Lens
2 Gudela Grote Errors and Learning for Safety: Creating Uncertainty As an Underlying Mechanism
3 Immanuel Barshi and Nadine Bienefeld When Silence is not Golden
4 Vincent Giolito and Paul J. Verdin Executive Perspectives on Strategic Error Management
5 Amy C. Edmondson and Paul J. Verdin The Strategic Imperative of Psychological Safety and Organizational Error Management
6 Nicholas Dechy, Yves Dien, Learning Failures As the Ultimate Root Causes of
Eric Marsden, and Jean-Marie Rousseau Accidents
7 John S. Carroll Understanding Safety Management through Strategic Design, Political, and Cultural Approaches
8 Ulrich Dirnagl and René Bernard Errors and Error Management in Biomedical Research
9 Jan Brommundt Empowerment
10 Julianne Morath and Mallory Johnson Open Error Communication in a High-consequence Industry
11 Robert Schroeder Confidence and Humility
12 Helmut Kunz Just Culture
13 Peter Klement Error Management in the German Armed Forces’ Military Aviation
14 Jan U. Hagen Crew Resource Management Revisited
15 Avner Shahal Error Reporting and Crew Resource Management in the Israeli Airforce
16 L. David Marquet Lessons from a Nuclear Submarine Mishap
17 Tony Kern The War on Error – A New and Different Approach to Human Performance
