The blame game

We operate in complex systems – social, economic, psychological, technological, etc.. They’re made up of interdependent parts, where changes in one part create changes in other parts. So, we should resist identifying single elements or individuals as the main cause of failure.

The aviation industry gets this. Pilots vigilantly record and share errors, analysing how they occurred in context. As a consequence, boarding an airliner far less risky than entering a hospital.

Last year saw 500 deaths in global aviation, a bad year, while thousands of preventable deaths occur every year in England’s NHS system alone.

Blame is lazy thinking, a failure to engage with the complexity of what happened. We need to investigate if we are to learn and improve. Pinning blame may satisfy an instinct for retribution, but it leaves us more vulnerable to failure.

A disciplined approach to getting feedback from systems is a big part of delegation.