The following important questions should be asked immediately by every employee:
- Who needs to be informed?
- What time window do we have?
- Which strategies are there for mitigation?
Everyone has to think along
Every affected employee is asked to think about the immediate measures. In terms of minimizing damage, it is essential to design and evaluate at least two strategies.
This creates contingency plans, which must always be supplemented, edited and updated.
Emergency plans will only work if the right time to intervene is not missed. This is an important goal of a functioning error culture.
root cause analysis
In order to draw positive knowledge for the future from an error, it is necessary to clarify which circumstances caused the error.
But it is not about the respective person! It is helpful to examine the connections and the background.
Possible causes of errors by employees are
- lack of specialist knowledge
- lack of skills
- emotional exceptional situations
- too little or wrong information
- individual knowledge deficits
- Pressure of time
- pressure to perform
- unclear target agreements
- too complex a process documentation
- organizational flaws
- unclear competence distributions
- leadership deficits
- technical deficiencies
- wrong decisions
- a lack of inner attitude
Several causes interlock
Often, several causes fall together or interlock. It is therefore not always easy to analyze the situation accurately.
The analysis is about persistently asking questions and not being satisfied with "first answers".
Difference to scapegoat culture
When the employee realizes how important the cause research is taken on the part of those responsible, he learns to use concrete and meaningful answers to help him uncover the real facts.
Here lies the great contrast to the "scapegoat culture": This usually protects only the underlying inadequate system in dealing with errors. The real reason does not always come to light immediately. Stay persistent in the search for clues! Helpful here is the so-called 5-times-demand method:
5 Times "Why" questions
Ask again for the first answer, and then again, five times in total. But do not ask "why", but better "for what reason" or "why".
Why questions are negatively intercepted by the communicative side, because they put us emotionally back into our childhood and school time:
Checklist for causes research
"Why did not you do your homework?" "Why is not your room cleaned up?" Already at that time we did not know any answer, this kind of root cause research in the "familial error culture" was not very effective.
- When did the error occur?
- When was he discovered?
- What exactly was the error?
- Which circumstances triggered the error?
- Where exactly did the error begin?
- How did it come about?
- What is the impact?
- Is it a single error or is there a chain of errors?
- Has the same error happened to other employees?
- Is there a risk that the employee will be able to make these mistakes again?
- Do errors always follow the same pattern?
- Was revision and / or overload in the game?
- Was it a communication, transmission or presentation error?
- Goods system factors responsible for the error (mit-)?
- Were environmental factors involved?
- What has already been done to mitigate the consequences?
- Can a control center be interposed if necessary?
- What has been done to avoid the error?
- What else can be done to avoid the same mistake in the future?
Quality and risk management
The link to quality and risk management, which has often been implemented for a long time, is the focus. The legal situation of error culture is also explained. As a result, the current situation is to be studied together.
- The questions to the participants in this phase of the workshop are:
- What is a mistake? How do we define errors?
- Where is the line between the terms "grossly negligent" and "deliberate"?
- What are the consequences of messing up mistakes?
- What does constructive error handling mean?
- Where are we now? Where do we want to go?
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