PS1) Amy Edmondson in "The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth" (2019)

"When people have Psychological safety at work, they feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. They are confident they can speak up and won't be humiliated, ignored or blamed...

 

They know they can ask questions when they are unsure about something... mistakes are reported quickly so that prompt corrective actions can be taken... and potentially game-changing ideas for innovation are shared...

 

In short, psychological safety is a crucial source of value creation in organizations operating in a complex, changing environment.” (p.xvi).
 

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PS2) "Creating Psychological Safety at Work in a Knowledge Economy"

by Amy Edmondson (3 minute video)

"I think it's always on the leader to go first and to do what he or she can to create psychological safety -- the ability for people to come to work and speak up about what they know... what they don't know... what they see ...what they're worried about... is absolutely mission critical to success in a knowledge economy."

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PS3) "Strategies for Learning from Failure"

by Amy C. Edmondson in Harvard Business Review, April 2011

"When I ask executives to consider this spectrum and then to estimate how many of the failures in their organizations are truly blameworthy, their answers are usually in single digits—perhaps 2% to 5%. But when I ask how many are treated as blameworthy, they say (after a pause or a laugh) 70% to 90%. The unfortunate consequence is that many failures go unreported and their lessons are lost."

 

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PS4) Why Teams Don't Learn from Their Mistakes (and How to Change That)

"In 2002, Dr. Gary S. Kaplan, the recently appointed chief executive of the Virginia Mason Health System in Seattle, visited Japan with some fellow executives. He wanted to see how organizations outside the health care sector did things. At a Toyota plant, Kaplan had a revelation... If a culture is open and honest about mistakes, the entire system can learn from them.”

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Since the new approach was taken, the hospital has seen a 74% reduction in liability insurance premiums."

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PS5) The Michigan Model: Medical Malpractice and Patient Safety at Michigan Medicine

(LOTS of links within)

• "The number of claims and lawsuits has dropped dramatically. In July, 2001 [before we launched our Open Reporting initiative] we had more than 260 pre-suit claims and lawsuits pending... We currently have just over 100.

• Our legal costs appear to be down dramatically, with the average legal expense per case down by more than 50 percent since 1997.

• The severity of our claims is rising far less rapidly than the national average.

• Our malpractice premiums are practically level, despite increases in our clinical business."

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Our approach can be summarized as:

“Apologize and learn when we’re wrong,

explain and vigorously defend when we’re right,

and view court as a last resort.”

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PS6) "What Is Psychological Safety?"

by Amy Gallo in Harvard Business Review

"Too many people think that it’s about feeling comfortable all the time and that you can’t say anything that makes someone else uncomfortable or you’re violating psychological safety,” says Edmondson. That’s simply not true. Learning and messing up and pointing out mistakes is usually uncomfortable. Being vulnerable will feel risky. The key is to take risks in a safe environment – one without negative interpersonal consequences. “Anything hard to achieve requires being uncomfortable along the way.”

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PS7) "Doctors Say ‘I’m Sorry’ Before ‘See You in Court’"

by Kevin Sack in the NY Times

"The number of malpractice filings against the University of Illinois has dropped by half since it started its program just over two years ago, said Dr. Timothy B. McDonald, the hospital’s chief safety and risk officer. In the 37 cases where the hospital acknowledged a preventable error and apologized, only one patient has filed suit...

 

...34 states have enacted laws making apologies for medical errors inadmissible in court, said Doug Wojcieszak, founder of The Sorry Works! Coalition, a group that advocates for disclosure. Four states have gone further and protected admissions of culpability. Seven require that patients be notified of serious unanticipated outcomes."

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PS8) Case Study | Embedding a System to Protect Patient Safety

by the Virginia Mason Institute, April 21, 2018

"from May 2005 to May 2015, professional liability claims saw a 74% reduction, resulting in considerable savings each year."

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PS9) Black Box Thinking: Why Most People Never Learn from their Mistakes, but Some Do by Matthew Syed

A great introduction to the applied psychology of human error. No jargon. No unnecessary academic terminology. Just powerful stories of real world errors and evidence-based ideas for how to manage them better.

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PS10) From Safety-I to Safety-II: A White Paper

by Erik Hollnagel

"Safety management should therefore move from ensuring that 'as few things as possible go wrong' to ensuring that 'as many things as possible go right'. We call this perspective Safety II."

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PS11) Virginia Mason's Clinical Transformation: Hard Work, Big Payoff
by Jeff C. Goldsmith February 7, 2011

"It required VM [Virginia Mason Health System] and its workforce to fundamentally rethink and renovate long established workflows, habits and routines. But most significantly, it involved redistributing power away from VM’s “owners”, the physicians, and enabling even the most junior nurse or aide on a patient unit to “stop the production line” by calling a Patient Safety Alert, triggering an immediate collaborative analysis and correction of defects."

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PS12) Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data
by Ann-Marie Howell et al., 9 Dec 2015

"The NRLS [National Reporting and Learning System] is the largest patient safety reporting system in the world.... The study did show that hospitals where staff reported more incidents had reduced litigation claims..."

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PS13) Promoting Patient Safety Through Reducing Medical Error: A Paradigm of Cooperation between Patient, Physician, and Attorney
by Brian Liang, 1 Sept 2000

"Patient safety has recently become a predominant health law and policy issue. It has been recognized that the vast majority of patient injury occurs due to medical error, and that systems analysis and lessons from other highly complex systems may be useful to reduce error and improve safety. Current medical efforts, however, focus upon individualistic "shame and blame" methods; such punitive approaches are antithetical to well-recognized systems that effectively reduce injury."

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PS14) 10 lessons for speaking-up: learning from Virginia Mason’s PSA system
By Aled Jones, December 13th, 2018

"The Patient Safety Alert (PSA) system was introduced in 2002 following a staff survey. This showed that staff were fearful of speaking-up about concerns. Also, staff doubted that information generated from concerns would improve the safety of care. At the time of the survey VM staff wishing to raise concerns had to complete a quality incident report (QIR). Typically, QIRs would sit on a shelf collecting dust for months, then filed away and forgotten."

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PS15) USS Benfold -- From the worst ship in the Navy to the best, in 20 months

• When Mike Abrashoff became Captain of the USS Benfold, he replaced traditional “command & control” leadership with a Learning-Based approach founded on Psychological Safety.

• Within 20 months:

  • retention rose from 28% to 100%

  • safety incidents dropped from 31 to 2

  • costs regularly dropped 25% below budget (p.28)

  • the crew won the award for the “most combat-ready ship in the Pacific fleet.” (p.30).

• “I found that the more control I gave up, the more command I got.” (p.6).