Learning from Big Mistakes

How about linking it to after action reviews?   Move closer to the process and the results.

How to Learn from the Big Mistake You Almost Make  by Kristen Senz

A brush with disaster can lead to important innovations, but only if employees have the psychological safety to reflect on these close calls, says research by Amy C. Edmondson, Olivia Jung, and colleagues.

What if businesses could learn from their worst mistakes without actually making them? How might the same progress and innovation occur, without firms incurring the costs associated with such errors?

The results of a recent study about close calls in health care suggest that when people feel secure about speaking up at work, incidents in which catastrophe is narrowly averted rise to the surface, spurring important growth and systems improvement.

“People don't pay enough attention, especially in the business world, to the potential goldmine of near-misses,” says Harvard Business School Professor Amy C. Edmondson, who studies psychological safety and organizational learning.

Incidents that almost result in loss or harm often pass unnoticed, in part because workers worry about being associated with vulnerability or failure. But when leaders frame near misses as free learning opportunities and express the value of resilience to their teams, the likelihood that workers will report such incidents increases.

That was the main finding of Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology, a study by Edmondson, the Novartis Professor of Leadership and Management at Harvard Business School, and Olivia Jung, a doctoral student at HBS. Co-authors on the paper, which was published in The Joint Commission Journal on Quality and Patient Safety, included UCLA physicians Palak Kundu, John Hegde, Michael Steinberg, and Ann Raldow, and medical physicist Nzhde Agazaryan.  ... "