[elliekelly]

I agree and it’s somewhat addressed in the book - if you find the premise at all interesting you should definitely read it, even if you’re skeptical of the practicality of implementing the philosophy (for lack of a better word) it’s interesting and the examples are compelling.

Some of the examples are whole-cloth cultural changes of entire industries (usually commercial flight actually, IIRC), but some are small, simple, changes that can be implemented by one or two people and still have a dramatic impact. One of the smaller-scale examples from the book that really stuck out was the attitude & approach of a surgeon in an operating room. When surgeons approach mistakes from the perspective of “okay, this happened, let’s focus on how we fix it” mistakes are reported to the surgeon quickly, the surgeon gets accurate information quickly, and can respond appropriately. Result: more mistakes are reported but the surgeon has fewer complications and better outcomes.

When surgeons approach mistakes by getting angry or assigning blame to the nurse who did X or the resident who did Y those surgeons have fewer (reported) mistakes but worse outcomes. Why? People don’t fess up because they fear the consequences. And when a mistake is identified, people don’t give accurate and complete information because their primary concern is KYA rather than fixing the problem at hand.