Forgive and Remember

You’re recovering from a major operation—which nursing unit do you choose? One that reports an error once every 500 patient days, or one that reports an error once every 50 days?

What if I were to tell you that in the first unit, which on the face of things makes 10 times fewer mistakes, nurses don’t report errors because they’re concerned that “heads will roll.” Would that change how you feel? How many errors are being swept under the carpet? Do you think that they’re likely to be learning from their mistakes or repeating them over and over again? (This example comes from Hard Facts, Dangerous Half-Truths & Total Nonsense by Jeffrey Pfeffer and Robert I. Sutton, Harvard Business School Press, ISBN: 1-59139-862-2.)

In software, we have our own name for mistakes—we call them bugs. And every bug is an opportunity to learn.

To read the rest of this article, take a look at Issue 6 of PragPub magazine

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