Table 1Individual and group “best practices” associated with a learning culture around mistakes

Best practice*Definition
Individual practices:
Habit of inquiryWillingness to engage surrounding individuals (superiors, peer colleagues, nonphysician co-workers) with respect to asking questions around mistakes, patient safety, and correct ways of doing work. Tendency to ask “why” in addition to “how” around the processes for identifying, investigating, and resolving mistake and near-miss situations.
Self-reflectionExtended self-examination of near misses and mistakes, in particular around how the near miss or mistake is being conceptualized by the individual and the larger lessons to be learned from it.
Personal forgivenessWillingness to forgive oneself for committing a near miss or mistake, not excusing one's part in the incident but not letting the event create untrue or exaggerated beliefs in the individual's mind.
Expressions of doubt and fallibilityWillingness to reveal to oneself and others concerns over “knowing all the right things” or “making a mistake.”
Sharing experiencesRegularly communicating to others personal stories and experiences about near misses and mistakes committed.
Empathy toward othersExpressing feelings and concern for those in the group who make mistakes and experience failure; a “there but for the grace of God go I” mentality that allows the individual to gain understanding from someone else's experience.
Systems thinkingThinking about or couching episodes of mistake or failure within the context of the total surrounding system of care, as well as contextual features of the individual's work life (e.g., fatigue) that may serve as contributory factors. Willingness to develop logics that link contextual factors to increased probability for the mistake or failure.
Group practices:
FeedbackHigher levels in the training hierarchy communicating down to lower levels specific aspects of why something is a mistake. Whether or not that communication is positive, negative, or valuable to lower levels, the communication provides information that allows the lower levels to understand the point of view and “norms” of higher levels.
Collaborative inquiryAdopting a collective approach to uncovering, examining, and resolving a mistake or near-miss problem. Employing a flattened rather than purely hierarchical approach to gaining and assessing information around the problem.
Reciprocal communicationCommunication moving both from top-down and bottom-up throughout the team, with less experienced members afforded equivalent chances of injecting their views, concerns, etc.
Creative tensionDisagreements in the group are tolerated, listened to, and resolved not by fiat but by trying to reach consensus, not limited to consensus of the most experienced individuals in the team. The group tolerates debate and disagreement where uncertainty is high around a mistake or near miss, using that disagreement to generate a variety of explanatory interpretations.
Real-time experimentationWillingness for the group as a whole, spearheaded by higher levels in the training hierarchy, to recast mistake or mistake events in a way that questions the underlying assumptions upon which the work leading to that mistake or mistake is done.
Real-time briefingsWillingness of higher levels in the training hierarchy to, at the moment a mistake is discovered or heard about, take a constructive approach to educating lower levels around ways to lessen the probability for such a mistake to happen again in the future.

These best practices are derived either explicitly or implicitly from a variety of management writings on the topic of learning organizations from scholars such as Senge (1990), Argyris (1991, 1996, 1999), Schein (1992), and Schon (1983).

From: Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians

Cover of Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings)
Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings).
Henriksen K, Battles JB, Marks ES, et al., editors.

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