By Mark SachsDirector of Client Engagement

“If a culture is open and honest about mistakes, the entire system can learn from them. That is the way you gain improvements.” Dr. Gary Kaplan, CEO Virginia Mason Health System

In my last blog, Apologies and the Future of Failure, I set the stage for today’s discussion about the need for cultural acceptance of human error in order to produce improvements that ultimately lead to fewer failures – what I would call success. I did so by discussing the importance of apologies as a moral predicate for producing constructive acceptance of error. 

Now, this is somewhat of a chicken and egg argument: does acceptance of apologies lead to acceptance of failure or vice versa? I’m not sure it matters. The fact is, we must understand the role failure has played in improving every aspect of our lives and how our new-found failure to accept its importance, particularly as it applies to cancel culture apologies, will prove detrimental to our continued improvements as a society.  

Thousands of people (pilots of all kinds and passengers) have died in airplane accidents stemming from human error. In the health care industry, current estimates range between 22,000 and 50,000 annual deaths associated with human error. In other words, people died at the hands of people who were entrusted to do no harm. What’s more, the estimated number of patients who suffer from serious complications may be ten times these amounts per year. That’s roughly 130 deaths and 1,370 preventable complications per day. How each industry dealt with failure, we will see, affects lives. 

In the aviation and health care industries, human error resulted, and is still resulting in the latter’s case, in significant deaths and complications. In the former, however, the number of deaths in aviation has decreased from thousands to a few hundred per year, while the number of flights has skyrocketed during that time. In 2013, according to Matthew Sayed, there were 36 million flights carrying more than 3 billion passengers, yet only 210 people died. This amounts to one accident for every 8.3 million take-offs! While changes have been adopted by some in the health care field, the decrease in human errors resulting in death and complications has not been as significant. 

A Culture That Promotes Blame and Stigmatizes Error Will Suffer from More Errors

Let’s take a brief detour to discuss a few important concepts: blame, mitigated language, and the narrative fallacy. “Holding people accountable and blaming people are two quite different things…[b]laming people may in fact make them less accountable. They will tell fewer accounts, they may feel less compelled to have their voice heard, to participate in improvement efforts” and as we discussed in Part I, many people are likely to double down on their error rather than reassess. The belief that one will be blamed, perhaps unfairly, silences those from whom we need to hear! 

A culture that promotes blame and stigmatizes error will suffer from more errors; it will fail to learn and grow. Conversely, a culture that avoids blame and destigmatizes human error will benefit from the knowledge these errors help expose.  

Mitigated language is the phenomenon found in social hierarchies: a junior person will modify their assertiveness when confronting a senior person. This is universal and found in every hierarchy. For instance, a co-pilot would likely not confront a senior pilot even in deadly situations. A nurse would not overrule a surgeon, even while witnessing a life-ending error, and a junior doctor would mitigate language to a senior physician. A junior cop is not likely to instruct a senior officer. A corporal would not countermand a captain. 

Narrative fallacy is a bias that forces us into a myopic view when assessing complex situations. Rather than recognizing a situation as complex, for any number of reasons, our brains want to simplify; moreover, the correlation between emotion and Narrative Fallacy is high. In other words, the more emotional we are, the more likely we are to avoid thinking through the facts and the more likely we are to create a narrative to support the way we feel. 

This means we apply simple answers to complex situations rather than taking time to test our beliefs. We craft a narrative to justify our initial response and it often comes in the form of blame. After all, blame is a far easier response, especially when emotions run high, than taking the time to sift through the facts.  

Let’s take what we now know and apply it to the aviation and health care industries. Aviation has worked to destigmatize human error while also creating protocols that reduce the impacts caused by the biases discussed above. Co-pilots are trained in assertiveness and senior pilots are trained in delegation and teamwork, all of which reduce hierarchy and increase effectiveness. Every plane has a black box from which errors can be assessed and corrected, therefore, serving to fact-check narratives. In the aviation culture, every error is assessed with full transparency. 

The health care industry, while improving, has much work to do. Nurses are still pressured to stay silent about known errors. Red Banyan is currently working on a whistle-blower case involving such a matter, and we have learned it’s not an isolated incident. Further, there are no black boxes in surgical rooms or patients’ rooms from which all actions taken by medical practitioners can be assessed. When a surgeon says to a family “we did all we could. He just didn’t make it,” was it true? How do we know? Was that just a narrative fallacy created because an easy explanation is simpler than a detailed examination of the facts? Or, perhaps self-examination is just too threatening to those who are tasked with prolonging life, not taking it. And, if one is willing to admit a failure privately, is the fear of blame and retribution too significant to admit it publicly? 

Failure Does Not Lead To Progress Because the Information That Undermines the Prevailing Beliefs Are Not Welcome.

All of this was a prelude to explaining the impact cancel-culture has on our culture’s ability to learn from human error. Cancel-culture is a form of blame culture and fosters closed loop thinking which 1) suggests that all information and all truth is known to those in a group or 2) the fear of blame is greater than the potential gain from the truth, so there’s no reason to hear alternative ideas. The result is that failure does not lead to progress because information that undermines the prevailing beliefs are not welcome.  

Let’s take a look at how our blame culture’s closed loop thinking impacted the way this country handled last year’s murder of George Floyd. The sequence of events that ensued following that terrible moment contained extreme levels of blame that expanded outward like a pebble thrown into a pond. What started with Derek Chauvin soon expanded to the three other officers, then wider to the entire Minneapolis police force, then engulfing all police, ultimately wrapping this country in a net of condemnation for its systemic racism. All this occurred in a matter of days. The farther the blame was cast, the less focused we could be on the facts of the case. 

As shown in previous examples, mitigated language is a natural human response. As far as I know, at least one of those officers was a rookie. What could be learned from this? 

The narrative fallacy ran rampant, given that protests erupted across the country, each the result of a simple narrative constructed to support a belief. After all, if one bad cop, or even a small group of cops, in one part of the country committed an egregious act, then there would be no reason for a city across the country to be set aflame but for a narrative that incites such actions. Members of Congress and others in the public eye were quick to cast blame and stoke the already burning fires. Nothing in this situation reflected open loop thinking, where errors, even egregious ones, are opportunities for improvement.  

The extreme culture of blame helped contribute to the highest levels of police retirement in history, the lowest levels of police recruitment in decades and the highest levels of violent crime ever recorded by the FBI. Though each one of us should have expected these consequences to result from an environment of blame, these could not have been the intended consequences of those who rightly supported justice for George Floyd. 

Did the process of blame that caused good police officers to resign help improve policing? Does rising violent crime and fewer available police to fight that crime help our communities? Would it have been better to retain the rookie cop on the force so he could not only learn from his tragic error but help instruct others about the hazards of mitigated language? I don’t know. I do know he’ll never get the chance. These conversations weren’t given the time and space to take place because too many people were quick to cast blame wherever they could. Cities burned. Dozens died. Billions of dollars were lost, and what did we learn? Justice for George Floyd could only have been achieved in a culture that reduces blame, destigmatizes error, and operates open loop thinking. 

Can An Idea Win In The Marketplace Of Ideas Only By Violently Casting Out All Other Ideas? 

Turning back to cancel-culture, wouldn’t it have been helpful to engage former Bachelor host Chris Harrison in a thoughtful conversation about race or how we should effectively judge someone’s actions when those actions took place during a time period when different moral codes prevailed? I believe it would have been constructive for everyone. Instead, he was shamed and fired, and we were left with the important discussion never having been broached.  

Can an idea win in a marketplace of ideas only by violently casting out all other ideas? Can’t we enjoy Winston Marshall’s soulful folk music and disagree with something he believes? Must his life be upended, and must we forego his talent? 

A culture/group that addresses circumstances with certitude and sanctimony cannot allow for human error because it presupposes that they too may make errors for which they would have to apologize. Such certitude and sanctimony do not allow for any information found outside that group’s knowable frame of reference. In essence, anything about which they do not already believe or know, cannot be true and must be subverted. This pattern is playing out in hospitals, public companies, schools, our political discourse, and amongst family and friends. 

A healthy, humble culture is one in which people are not condemned for ideas or blamed for errors any one of us might have made under the same circumstances. A healthy culture demands some thoughtful perspective finding. It requires humility. It requires us to be able to apologize for an error we commit and accept apologies for those errors committed by others. 

To disrupt this pattern, here are a few suggestions we should all take into consideration:

  • Allow for what others believe
  • Approach important conversations with humility – none of us has all the information
  • Destigmatize human error (this does not mean there are no consequences)
  • Encourage those who have made errors to step forward to accept responsibility without fear of personal destruction
  • Recognize how important human error is to our long-term well-being. 
  • Weigh the facts before we force someone to bear the burden – they may not deserve it.