Learning Lessons from Incidents

All organisations experience “Incidents”. Some call them by other names: “Near Misses”, “Mistakes”, “Errors & Omissions”, “Operational Errors”.  Some are big and have damaging consequences (e.g. a data breach), and some are small and might be classed as “an annoyance”, e.g. email down for 10 minutes (though some might find that a positive). Whatever the incident, you should consider each of these as a “learning opportunity.” An opportunity to improve a process or avoid costly errors.

In his book Black Box Thinking, Matthew Syed described learning from incidents and adopting a “Just Culture” where individuals are encouraged to report errors / mistakes and are not punished/blamed.

The starting point is to accept that incidents will happen and that 95% of the time it is because of poor process. Encourage people to report their mistakes and don’t beat them up for human error. Understand why it happened and what measures can be taken to avoid a re-occurrence. Update your processes and procedures as required and then communicate the changes/lessons learned to all relevant stakeholders.

Consider further if the incident required the invocation of a “response plan”. How was it handled?  Did the response plans work? Did people know what to do? Were actions taken in a timely manner? Is there anything you would do differently next time? For example: change the sequence of actions, include some additional steps/actions, call in an expert earlier in the process, communicate with customers earlier and let them know what is happening.

Take these learnings into account when you review/revise your response plans. Share your experiences with peers and encourage them to share their experiences with you (do this in a safe/secure sharing environment). Smart people learn from their mistakes, but the really smart ones learn from the mistakes of others.

To learn more about managing and reporting on Incidents, contact us today to request a free tailored demo.

 

 

 

 

 

 

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