Nine Steps to Move Forward from Error

Abstract:

Following celebrated failures stakeholders begin to ask questions about how to improve the systems and processes they operate, manage or depend on. In this process it is easy to become stuck on the label ‘human error’ as if it were an explanation for what happened and as if such a diagnosis specified steps to improve. To guide stakeholders when celebrated failure or other developments create windows of opportunity for change and investment, this paper draws on generalizations from the research base about how complex systems fail and about how people contribute to safety and risk to provide a set of Nine Steps forward for constructive responses. The Nine Steps forward are described and explained in the form of series of maxims and corollaries that summarize general patterns about error and expertise, complexity and learning.