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reframing mistakes

©  mary frances art

© mary frances art

The long summer days are here, and so I’m signposting a longer-than-usual read.

This essay by Ian Leslie in the New Statesman tells the story of an airline pilot who is using his knowledge and understanding of accident analysis in the aviation industry to help the NHS learn from errors and mistakes in health services.

Ian’s essay usefully challenges our belief in perfect practice outcomes, highlights specific features of hierarchical communication which compound human error, and points towards constructive shifts in organisational culture.

An engaging and inspiring read for anyone with an interest in systemic learning and change – highly recommended.

‘how mistakes can change lives

29 June 2012


fiona duggan:  I read the article yesterday evening and woke up this morning still thinking about it. I regularly see the same situation in building projects, though, thankfully, lives are generally not at stake. When projects don’t progress as expected, it’s usually a whole raft of miscommunications, mostly minor oversights and, occasionally, priorities that have been lost sight of while conversations and effort are concentrated on a particular detail. So much of what the article raises resonates – mistakes arise out of coincidence (the coming together of several things in a particularly unfortunate way), it’s almost never one person’s fault and at least one person in the situation has flagged the problem. The article so clearly articulates the complexity of situations as they emerge.   And I very much like the ‘leadership’ style of this quiet revolution towards greater understanding and fewer tragic mistakes. An inspiring story about an inspiring person, and those who had the courage to join him in dialogue. What an achievement – to have created a situation where all concerned felt safe enough to  ask what’s going on when things go wrong, and then look at what can be done to make things safer for everyone in future situations. Martin Bromiley is an extraordinary role-model for our times.  30 June

john randall:  Many thanks indeed, this was absolutely fascinating. The inability to speak out to senior staff in hierarchical systems is a curse and is brilliantly exposed here, showing how those embedded modes of communication (and non communication) disable us and we cannot pull ourselves out of a nose-dive even, or especially, in the most desperate circumstances. Martin Bromiley’s work is to be applauded for helping make the patterns so clear, and for showing the way to gradually transform the culture of huge and complex organisations while avoiding blame entirely. A great read.   30 June

liz thomson:  I had also read this article and thought that it said some very important things about the way that we construe ourselves as learners and in particular the need to be able to not only give ourselves permission to make mistakes but to recognise the deep learning that occurs when we do.         I was reminded of a discussion I had many years ago now with some doctors at a conference when they were quite insistent that they could not make mistakes!  Two things struck me at the time, i) they were clearly presenting their public persona and were concerned not to be seen making mistakes as that would affect their construction of themselves as professionals, and ii) the fact that they were pathologists was interesting insofar as they didn’t get patient feedback and the likelihood of litigation was minimal!      2 July

armando magnino: Thank you, that was a very interesting article. I look at it from a “design” perspective and what I see from that point of view is that the solution is one of designing  better systems (reviewing the role of the hierarchy to improve communication, introducing check lists) rather than focusing on individual competence and expertise: the crews had all the information needed but the system didn’t allow the information to flow. It reminds of when I was involved in groupwork and the importance we placed in making sure that all the voices were heard.
One of the bits that caught my attention was the brief section about the two levers confusing the pilots… Donald Norman in his book “The Design of Everyday Things” (originally published as “The Psychology of Everyday Things”) talks at length of how we tend to blame ourselves for what are in reality failures of design. You approach a door and try to pull it instead of pushing it… and you think “I’m such a klutz!” and take it as a personal failure, when in fact a well designed handle should give you the information you need. One of the requirements that Steve Jobs set for the first iPods was that whatever you were trying to do, whichever sub-menu you were trying to reach, it shouldn’t take more than 3 clicks: how many people trying to navigate a complex set of sub-menus give up saying “I’m hopeless at technology”?
However, there is a school of thought that says that there is such a thing as risk homeostasis (I came across it in Malcom Gladwell’s “What the dog saw”): if you make the system safer, people will take more risks. I guess, as in the article, what’s needed is a two-pronged approach of improving systems and changing cultures.   9 July

mary:  Closely related to this item, there is another article in NS today regarding the announcement of a plan to ‘name & shame’ doctors who miss cancer symptoms. An extract:

Fear is a grave risk to patient safety. Shame as a policy satisfies our desire for a simple explanation, a bad doctor for example. This is an ancient myth we tell our children and ourselves; if we can identify the bogeymen, in this case the bad doctors, then we’ll be safe. Shame is also the product of a desire for retribution. Behind policies designed to shame people are not simply newspaper editors looking for headlines, or politicians looking for simple answers to complex problems, but aggrieved relatives, policy-makers or journalists trying to cope with a delayed diagnosis or a medical error. Their concerns deserve to be taken seriously, very seriously indeed. But if shame continues to shape policy, it will be a disaster for patient safety.”

The link is: http://www.newstatesman.com/politics/2014/07/diagnosing-cancer-why-shaming-and-blaming-gps-isn-t-about-improving-patient-safety






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speed ninjas v turtle walkers



An interesting item appeared on the LSE impact blog from Filip Vostal titled ‘In Search of Scholarly Time’. He argues for an alternative to both speed-driven time-management on the one hand and the “regressive ethic of slow scholarship” on the other.

He is critical of what he experiences as the prevailing culture of haste “accompanied by the rise of bite-size science, academic speed-dating and ‘business accelerators’”, and he questions the popularity of Productivity Ninja training which emphasises skill and ruthlessness in “dealing with the enemy that is information overload”. His argument concerns the potential of these approaches to render increasing workloads, time-shortages, alienation, and burnout as personal and individual issues, rather than stressing their origins in the changing structural features of organisations.

On the other hand, Vostal is also wary of calls for slowness which he sees as “a deeply problematic rival” to the culture of speed. Speed, he proposes, is “chosen, desired, appreciated – either as an instrument or as goal in its own right implicit in the idea of progress and the realization of a better future … a force profoundly entrenched in the modern individual’s mind-set.” By contrast he suggests that slowness is traditionally understood as regressive, idle and reactionary, exemplified by Walter Benjamin’s description of C19 flâneurs protesting against increasing industriousness by taking turtles for a walk.

He highlights the potential lack of quality and short shelf-life of hasty scholarship, and I wonder whether this from Jerome Bruner might also be relevant (coming from the the side of the turtles): “Having read a good many journals and diaries by writers I have come to the tentative conclusion that the principal guard against precocious completion, in writing at least, is boredom.

So what, Vostal asks, is scholarly time? He suggests that while it is unhasty in principle, “it is not slow by default as it needs to accommodate accelerative moments of inspiration and intuition (eureka and aha moments) and attend to practical features such as digital search engines and databases.”  He sees scholarly time as a counter-strategy to speed culture, based primarily in conscious autonomy over our use of time, which he proposes as an essential critical resource. “Democratic decision-making, deliberation, will-formation, and policy implementation need to be underpinned, as Robert Hassan says, by natural unforced rhythms (which do not have to be slow). This principle seems entirely salutary – if not straightforwardly necessary – in the academic environment….and perhaps as an ethical principle integral to education and science governance.

His column called to mind an interview with photographer Rachel Sussman who commented on the way things reveal themselves by paying continued attention, a process she describes partly as perseverance, and partly “something that I think is so vital to the creative process, something that Steven Johnson writes about in Where Good Ideas Come From, this idea of the “the slow churn” … just following these different paths, the things that intrigue you, and allowing them to simmer in there until something fires in your brain and all of a sudden these connections happen. I did have the a-ha! moment — but it probably was a year and a half in the making.

read the blog here

26 May 2014




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hitting the live rail

electricity_warning_signs_-_Google_SearchOne of the most interesting and challenging organisational case studies we are living through today must surely be the BBC, exposed as it is in this post-Savile, mid-Clarkson moment.

Clarkson, the star of a comedy programme about fast cars with a relentless irreverence for anything that could be referred to as political correctness, has, in the words of Musa Okwonga “finally urinated on the live rail of racism, the “N-Word””. The response has been horror and outrage, much of which has been rejected and ridiculed as disproportionate; support and defence, on the grounds that it was part of a well-known children’s rhyme and not actually broadcast on air; and a brief managerial statement from the BBC as follows:

We’ve received complaints regarding Jeremy Clarkson allegedly using a racist term during the filming of an episode of Top Gear. Jeremy Clarkson has set out the background to this regrettable episode. We have made it absolutely clear to him, the standards the BBC expects on air and off. We have left him in no doubt about how seriously we view this.

The term ‘institutionalised racism’ was introduced to the British public by the Macpherson report following the Stephen Lawrence inquiry in 1999. Resisted and argued with at the time, our institutions are still having the greatest trouble understanding what it means, or how it works. A good example might be a response to a serious complaint of racism which is limited to the statement that it is taken seriously and that formal standards have been reiterated.

Musa Okwonga’s passionate and crystal clear piece in the New Statesman was reluctantly posted since he is, quite understandably “fed up with being expected to serve up elegant, dignified and dispassionate responses” to every “finely-calibrated jibe”, but ‘like a sleepy bear who has had its belly prodded once too many times with a spitefully sharp stick, here I am.” He makes very clear the ripple effect of such casual racism. It “is the kind of thing that landlords think when they are deciding not to let properties to black people. It is the kind of thing that led to the racist van campaign. The kind of thing that brings your kids home from school in floods of tears, that makes employers think twice before calling you to interview. It is insidious and it is widespread.

A strong culture-setting response from the BBC would require that Clarkson be moved or sacked, but removing him from the show would seriously damage their number one best-selling product worldwide, so the consequences of either choice become problematic for them. Clarkson’s jokey-blokey style of bantering offensiveness has been indulged and promoted for a very long time. As Laurie Penny wrote recently about UKIP, the “language of popular television comedies, complete with awkward racist blunders” is widely accepted, and outright prejudice is increasingly acceptable “so long as it’s dressed up in silliness and accompanied by a farting trombone”.  Organisations can easily find that they have painted themselves into tight corners from which a graceful exit seems impossible. A lack of sensitivity over time leaves little flexibility for action when incidents like this arise – having supported and excused such behaviour for so long there will be no particular logic in calling time on it now.

It is easy enough to lose sight of the inevitable gap between the framed statements on the Board Room wall and the everyday talk and behaviour of people at work. An organisation which tries to understand disadvantage and prejudice will work hard to keep an eye on what is happening and will continually strive to minimise the gap. Organisations with less awareness are uncomfortably surprised when they hit a live rail and the gap is exposed, and they may seek to hide it where possible or justify it where necessary.  A brief statement telling us that the issue is taken seriously – especially when it still refers to the video-recorded comment as ‘alleged’ – is not what is needed. But neither are guilt and blame necessary, if that’s the fear which is holding back progress. We have more choices than that.

Alternative responses are likely to be based in determination and genuine curiosity about how to work better with these disturbing incidents; in opening conversations with an interest in learning from experience; in an honest facing-up to the problematic reality of espousing corporate values while behaving otherwise; in an exploration of what the organisation represents, what it stands for, what is incompatible with that, and what to do about it; and in living without any instant solutions as we stumble towards a way forward through trial and error and a sustained paying of attention.

The aftermath of racist incidents presents a critical moment. Nothing will be easy, but the response could be forward-looking, creative, even inspiring. It could open issues up instead of closing them down. The current political climate is unhelpful, but the challenge will not go away – if anything, the argument is getting louder. There is so very much to learn, and there are many alternative ways to start.

Musa’s column is here: http://www.newstatesman.com/media/2014/05/n-word-jeremy-clarkson-has-finally-urinated-live-rail-racism

5 May 2014





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the wrong kind of narrative

Image courtesy of Andrew Ormston

Image courtesy of Andrew Ormston

The Ecologist recently featured an interesting piece by Vanessa Spedding. It was inspired by dismal media coverage of climate change issues which habitually reverts to questions of whether it is ‘true’ or ‘real’ and uses opinionated non-experts as default commentators. Spedding explores media coverage and our responses to climate change through a narrative lens, and her piece raises interesting questions about organisational narratives at times of serious threat.

She recognises that we look to stories to make sense of our world and to find direction and meaning. ‘The media craft stories that are appealing in part because they give us contexts and comparisons for our lives. We may know, if only instinctively, that we are taking part in a bigger story – the story of our community, our culture, humanity, the planet. And if we can write our life story so that it contributes in some small way to that larger story, we can achieve a sense of being on a hero’s journey of our own.’

Spedding describes the dislodgement which happens when major threat undermines our current story-making by confronting us with evidence that our well-intentioned behaviours are contributing to a catastrophe. ‘We can no longer be heroes’ she tells us, and ‘we can suffer such a profound loss of meaning and purpose that we prefer to shut out the knowledge of the new story direction’.

She explores the ways in which communities, organisations and institutions will tend to foreground validating stories of growth, progress and winning, and will resist changing narrative trajectory to avoid a crisis of validity and identity, not least in their own working cultures and organisational myths. Climate catastrophe, she tells us, is the ‘wrong sort of narrative’.

She acknowledges the difficult prospect of announcing ‘Now today’s top story, the end of civilisation …’  and suggests that the BBC’s emphasis on uncertainty in their coverage, which it defends, unconvincingly, as impartiality, represents this fundamental disconnect. She argues eloquently for the urgent need to shift the frame of reference for our stories, and for the courage to end this ‘intellectual paralysis’, proposing alternative stories we could be hearing, such as potential policy responses and examples of inspirational grassroots activity.

Her conclusion is itself inspirational: ‘The media has the power to facilitate a transformation of our society. Climate change and ecosystem decline could provide a unique opportunity to focus on exciting, inspiring, uplifting news … what they need is an invitation, from us their customers: to weave us all into new stories and to reset the compass for our lives.

You can read her piece (and sign her petition) here:

24 March 2014




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science says so

Images courtesy of the Wellcome Collection

Images courtesy of the Wellcome Collection

Neuroscience has quickly gained traction in the organisational world, perhaps not surprisingly as so many neuro-studies appear to offer clear and incontrovertible findings – such things are prized in the field.

The house magazine of the Chartered Institute for Personnel & Development is regularly padded with features such as this week’s proposal that we “ditch the clean desk policy” Why? “It’s science that says so”. These items now commonly contain neuro-references – for example we are advised that we are most creative when we are idly reading or daydreaming, and how do we know this?  “Brain imaging shows us”.

Their latest e-update promises the “recent neuroscience findings that are crucial to being an effective leader”. One of the ‘secrets’ revealed is neuroscientific evidence that cheerfulness “inspires employees and leads them to work harder”. Conferences are similarly featuring presentations on many behavioural topics telling us that ‘science proves it’ accompanied by brightly-patterned brain scans on a powerpoint slide.

I am finding it hard to distinguish these items from the features we see every day in the free papers handed out at the station. I can be as seduced as anyone by neuro-images – they’re beautiful and full of wonder – but I have been equally impressed by the stories of grad students producing significant multi-coloured activity in the brains of dead fish.

So it’s good to find a serious and thoughtful exploration of the significant potential of neuro-research in social sciences which avoids conflating brain, mind and self, and which prioritises context and meaning. I am enjoying working my way through Neuro: The New Brain Sciences and the Management of the Mind by Nikolas Rose and J.M. Abi-Rached, Princeton University Press (2013).

we must recognise that the brain is embodied…[and] the embodied brain is intrinsically, not just extrinsically, enmeshed in its social and cultural and experiential world……unless you understand the social embeddedness of neurobiological processes, and of biological processes more generally, you simply won’t understand the phenomena that you’re trying to explain.’

You can read the introduction here:

and there is an excellent interview with Rose about the Human Mind project on the LSE website here:


Like all Rose’s work the book is interesting, challenging, with much food for thought. If you read it I’d love to hear your views.

12 February 2014


dina pekkala: You are right, there is something so seductive about neuro-imaging…it appears to give us a definitive truth, which although on many levels, many of us recognise the illusion of this concept, there are occasions when it would be oh so nice ‘to be sure’…we don’t need to think about it…we don’t need to evaluate it…it is a given from up on high so it has to be right. Which I guess takes us onto your beautiful quote from Rose: ‘unless you understand the social embeddedness of neurobiological processes, and of biological processes more generally, you simply won’t understand the phenomena that you’re trying to explain.’
My doctoral dissertation was a qualitative exploration with teenagers with ADHD of their understanding and meaning making of their diagnosis. From my observations and their accounts it was evident that the ‘social embeddedness’ of their ‘disorder’ was so often overlooked; ADHD was (and still is to a greater or lesser degree) construed as a biopsychosocial problem…with a heavy emphasis on the BIO…hence, treat with Ritalin and never mind the context of the ‘disorder’. Interestingly, I’ve often seen a parallel between the symptomatology of ADHD and PTSD. If we explored ADHD with that in mind…I wonder what it may tell us about the ‘social embeddedness’ of the ‘disorder’? 14 february

richard casebow: The social rhetoric of neuroscience is an interesting topic. There was a great book by Jean-Pierre Changeux and Paul Ricoeur in a dialogue about the merits of neuroscience models. As a constructivist, I am with Ricoeur in that ultimately words slip around at different levels in the models, so that there are glaring gaps and inconsistencies. Changeux gives a great elaboration as to why this might not be and demonstrates a wonderful weaving of scientific thought and philosophy that is characteristic of French education and often lacking in the Anglo-American world.   14 february



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