This website covers knowledge management, personal effectiveness, theory of constraints, amongst other topics. Opinions expressed here are strictly those of the owner, Jack Vinson, and those of the commenters.

To Err is ... System

“To err is human” is a well-known phrase. It generally references the reality that humans are fallible and imperfect. It comes from the longer quote by Alexander Pope, “To err is human, to forgive divine” from his Essay on Criticism. (It’s a fun read - the opening really rails against people who would criticise those who create, and it goes on to propose a better way to approach criticism. And it contains another classic line, “For fools rush in where angels fear to tread.”)

Good nature and good sense must ever join;
To err is human; to forgive, divine.
— Alexander Pope - An Essay on Criticism

I am inspired to change this a bit. People operate in a world defined by beliefs and rules and processes - they live inside a system. And as most people want to do the right thing, when errors happen it is usually something that results from the way the system operates. People don’t intentionally commit errors and mistakes*.

The challenge for us is how to manage when the inevitable error occurs. Do we blame the person who “made the error”? Or do we step back and think about what allowed the error to happen in the system? Is there a measure or implicit expectation that the person is operating against that allowed the error to get through? Is there a physical design of the space / tool / form that makes it easy to make mistakes? Are people overwhelmed with mixed messages and too much work that causes confusion and increases the potential for errors?

Systems thinking guides us to step back and look at the system. What created the environment in which the error occurred? Even beyond “errors”, what makes the system operate in some way that we find objectionable? What is the system that we are describing? What do we WANT from the system? Then we can dive in and look for understanding behind what is creating the undesirable results. It is incredibly rare that the root cause can be placed at the foot of an individual. It’s the system.

I was also inspired by a recent podcast from Mark Graban, Mike Eisenberg, The Film “To Err is Human” and the Patient Safety Emergency. They talk about how the design of systems in hospitals can lead to errors, and yet the name of the film is about human errors. It is the human system that we created.

* Yes, there are people who do these things intentionally. But they are few and far between, and I am not particularly interested in “solving” for them.

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