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“In my department, we refrain from disciplining team members who make inadvertent human errors or mistakes.”

Particularly for those with a safety background, this statement is aspirational. To create a learning culture within an organization, leaders and peers must create a psychologically safe space for team members to raise their hands and say, “I’ve made a mistake.”

In our Just Culture Benchmark Survey1, we ask respondents to express their level of agreement with the statement above. Separate from our client survey work, we have also collected responses from over 1,000 randomly selected U.S. workers across 12 industries, including healthcare, aviation, policing, emergency medical services, energy, construction, manufacturing, utilities, research laboratories, hospitality, as well as K-12 and higher education.

Respondents, on average, report working in a punitive culture, with 55.3% of respondents indicating that their organizations discipline human error.  As shown in the table at right, police (69.1%) and aviation (67.6%) are most punitive toward human error, while education (HiEd: 34.1%, K-12: 48.2%), research labs (50%), and healthcare (52.5%) are least punitive.  The differences between the most punitive and least punitive industries are each statistically significant (p < 0.01).

In extreme cases, we invoke the criminal law using the legal system’s language of negligence.  The prosecution of Minnesota police officer Kim Potter, who took the life of Daunte Wright by mistakenly grabbing her gun rather than her taser, is a testament to a society demanding perfection of its citizens.  For the employee who is disciplined, the person being harmed, and a society looking for better outcomes, there is little to gain from our punitive nature toward human error.  That said, there are things we can do:

1. Reduce the rate of harm

Over the span of 20 years, from 1960 to 1980, the rate of commercial aircraft accidents in the U.S. dropped by 98%.  More than 50 years ago, the Federal Aviation Administration mandated that if the installation of an incorrect part or material could endanger flight safety, the technician performing the maintenance involving that part or material was prohibited from doing the task alone.  Such is an example of good system design, putting flying passengers further than one mistake, or one bad mental model, away from harm.  With the push to punish or prosecute human errors that lead to harm, the obvious best strategy for your staff members, and your customers, is to prevent harm in the first place.

2. Revise your disciplinary policies

While the legal doctrine of employment-at-will provides an organization the latitude to terminate an employee for good cause, no cause, or bad cause, it is hardly the path to a learning culture.  An organization can and should make the unilateral commitment to employees that they will not face disciplinary action in response to an event for any conduct falling short of reckless behavior, regardless of the severity of the outcome.

3. Conduct a complete root cause analysis (RCA)

By conducting a meaningful investigation, we can develop understanding and empathy for another person’s experience and by doing so, we can direct our focus on the real work of safety improvement, rather than on our generally punitive, self-righteous response of “I’d never do that.  I’m a good employee.”

4. Take organizational ownership of the event

Take organizational ownership for your successes and failures, alike.  In the case of actual harm, this would include transparency, a formal apology, compensation, and a commitment to implement preventative measures to avoid future harm.  While seemingly self-protective, turning on your employee who makes a mistake is a path leading away from high reliability.

5. Reject No Harm, No Foul

In a Just Culture, we judge the quality of a person’s choices, not the triumph or tragedy those choices produce.  We believe that ninety-nine percent of workplace justice happens ahead of harm, and when harm does occur, we commit to doing exactly what we would do had there been no harm.  The more we convince ourselves and our community that attention should focus on the quality of our collective choices ahead of harm, the less likely we’ll see the harm caused as the reason for punitive sanction.

6. Express a fierce intolerance for reckless behavior

Prior to our invention of criminal negligence, criminal liability generally hinged upon our collective ability to choose between good and evil (recklessness being the floor for the latter).  Words like non-punitive and blame-free, often used by safety advocates today, can unfortunately be perceived as a desire to create a world free of personal accountability.  Not all undesired conduct is caused by external forces, bad system design, or poor organizational culture.  Psychological safety and personal accountability can and should coexist.

7. Educate professional boards, regulators, and the press

If the goal of professional boards, accrediting bodies, and state and federal regulators is to keep the public safe, they too should adopt the tenets of Just Culture.  Through the Patient Safety and Quality Improvement Act of 2005, we enacted federal laws to protect those who report errors in healthcare.  Many professional boards have brought Just Culture concepts into their licensing evaluation process.  Through the Aviation Safety Action Program, we have shown that regulatory, business, and labor partnerships are not only possible, but productive.  We have even seen hospitals bring the local press into their Just Culture work, striving to create reasonable societal expectations ahead of harm.  Educating external stakeholder groups can stem the tide in our demands for perfection.

It is possible to create a psychologically safe learning environment within our workplaces.  Yet, through our elected officials, we wrote laws criminalizing human error, and through human resources policies, we turned anything less than perfect performance into workplace misconduct warranting disciplinary sanction.  It’s no wonder, across every industry we surveyed, that employees so clearly see the punitive culture we deliberately designed into the system.

Cite as: Marx, D. & Huntsman, D, (2024). Re: Human Error, We Live in a Punitive World. The Data Series, (1), 1–2. www.justculture.com

David Huntsman, a Ph.D. data scientist, leads the survey work at The Just Culture Company.

David Marx, is a systems engineer with a juris doctorate in law.  He is the founder of The Just Culture Company.

1 The Just Culture Benchmark Survey is a device for evaluating workplace culture using nine key behavioral markers tied to seven generally universal organizational values: customer service; patient/customer safety; employee safety; financial stewardship; data privacy & protection; environmental protection; and diversity, equity and inclusion.  We use the survey, and its associated Just Culture Improvement Index, as key measurement tools aiding organizations’ implementation of Just Culture.

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