The book begins with a tragic story of how a 37 year old mother died during a routine surgical procedure. Martin, her husband, was told by the doctor that ‘it was a one-off’. Although a number of unforeseen events had taken place during the procedure, no attempt was made to consider if things could have been done differently and procedures improved for future operations.
However, Elaine’s husband, Martin, was an airline pilot. In this industry there is a different attitude to failure.
Martin was persistent and the hospital carried out an investigation. The findings included recommendations for improvement. These included the need for better communication during surgical procedures so that any member of staff feels comfortable to make suggestions on treatment, and allocating a member of staff to record the timing of events. (During the operation that went wrong the surgeon was unaware of how little time they had left.)
By contrast, every incident in the airline industry is thoroughly investigated to establish what went wrong, to learn from it and make changes to reduce the risk in the future. This may be because one plane crash has devastating consequences for a large number of people, but it is not because more people die due to human failure in the airline industry that in healthcare. In 2013 a study in the ‘Journal of Patient Safety’ put the number of premature deaths due to preventable harm at 400,000 per year. This is more than the equivalent of two jumbo jets crashing every day.
The book identifies that a key reason for a culture of not examining failure: ‘Because we are so willing to blame others for their mistakes that we are so keen to conceal our own’.
Rather than blaming others ,‘Black Box Thinkers’ learn from their mistakes. The book identifies examples a divergent as James Dyson, David Beckham and Steve Jobs along with many others
One of the concepts he discusses is Cognitive Dissonance, a situation involving conflicting attitudes, beliefs or behavior, which can produce a feeling of discomfort leading to actions to reduce these feelings. An example he gives is the way Tony Blair continued to justify the Iraq War in the light of increasing evidence that Weapons of Mass Destruction had never existed. The earlier statements are, of course, first:
‘His WMD programme is active, detailed and growing.’
‘I have no doubt that they will find the clearest possible evidence of Saddam’s weapons…’
‘I have to accept that we haven’t found them and we may never find them, we don’t know what happened to them…’
‘The world is a better place with Saddam in prison…’
The room was too hot.
Participants were Dutch (they always mark low).
An important football match was taking place.
I think what the client asked us to cover was too difficult for the participants to understand.
There were one or two participants who ruined the programme for everyone.
I won’t say how any of these relate to programmes we have run. However, it shows how easy it can be to blame others rather than reflecting on failure and trying to learn from it. All of us need to keep reminding each other of this or we will lose opportunities for improvement.
This book is rich in content, and includes a large number of examples; I made a large volume of notes as I read it. I won’t try to reproduce all the interesting content. Firstly, there is just too much of it and secondly Matthew Syed is a much better writer than me. I strongly recommend the book to you.