Strategies for learning from failure.
Failures are inevitable in any industry, especially in one as complex as health care. The ability to learn from failures is a crucial characteristic of high reliability organizations, and creating a climate that emphasizes organizational learning is an essential element of safety culture. This article draws a distinction between preventable failures in predictable operations—which are largely due to slips, and can be prevented by interventions such as checklists—and unavoidable failures in complex organizations, which should be reported, analyzed, and treated as learning opportunities. The author, who has extensively analyzed high-profile failures in many industries, recommends that organizations maintain a learning culture, actively promote detection and reporting of problems by frontline staff, and promote experimentation and creative problem-solving in order to minimize the stigma of failures and enhance organizational learning from unexpected events.