We make mistakes, learn from them

While we all make mistakes, a culture of accountability is an absolute need in all societies, at all levels, in all sectors. We don’t particularly want witch hunts, blame games, or finger pointing, we just want to know that if something goes wrong once, it will not go wrong again.

The old adage that “You learn more from your mistakes,” is one of life’s great truths, and you will all have experienced that sensation of déjà vu, when some set of circumstances is occurring, not for the first time in your life. That sensation, that feeling, then gives you pause... a moment to reflect... and you will absolutely, positively, not go down the same path again. It is God’s reward to those who listen. And of course, if you take no notice, and continue forward anyway, you will surely pay the price.

“Mistakes,” said actress Sophia Loren, “are part of the dues one pays for a full life,” and I guess that may well be true and she was in good company, as I think the unkempt, yet remarkably intelligent Albert Einstein said, “Anyone who has never made a mistake has never done anything new.” It probably leads us on a tangent too, to understand that if we are to celebrate and acknowledge our successes, then to be true to ourselves, we must not only learn from our mistakes, but ensure that others too learn from our mistakes.

In 2005 Elaine Bromiley was to undergo a minor, and very routine nasal surgical procedure. At 37, and with no evident health conditions, it was to be a simple process, however after the patient was anaesthetised, the surgical team was unable to insert a device to keep her airways open. Reluctant to perform an emergency, front of airway tracheotomy of the type you see in television medical dramas every week, Bromiley was brought out of anesthesia, and though breathing erratically, was moved to a recovery suite. Tragically, she never fully recovered, and despite intensive care, passed away thirteen days later.

Her husband, airline pilot Martin Bromiley never went looking for blood. Instead, he turned his energies in two directions. Bromiley initiated an enquiry, not to apportion blame, but toward any of the medical professionals involved, but rather to identify and circulate any learnings from his wife’s demise, and secondly, in a remarkable display of compassion, Bromiley now works directly with the National Health Service to create an effective culture of responsibility and accountability among healthcare professionals.

Interestingly, he has drawn from his profession as an airline pilot where all and every mistake or error, must be reported, analysed and reported upon by independent review. The findings are then circulated to all pilots who must confirm they have read and understood the findings, implementing any findings. It is a culture that removes blame, replacing it with continuous development, and is perhaps one reason why, in 2010, you would have been 30,000 times more likely to die in surgery, than in an airline flight.

Martin Bromiley has single-handedly changed how the world’s largest public health system operates, by introducing Human Factors and Ergonomics (HFE) to surgical operating theatres. “It is a scientific discipline that aims to understand how humans behave in a system and how to optimize the system design, to make it easy for people who work in high-risk industries such as in healthcare, and have to perform complex tasks, to do the right thing,” said Bromiley recently, “making it difficult or ideally impossible, to do the wrong thing in stressful situations.” In fact, he told a recent audience, “The intent of HFE procedures is so much focused on safer outcomes that airline pilots can not be sacked for making mistakes, thus developing an industry wide acceptance of the process.” The reality is that we fear mistakes because we may lose our jobs, when we should more fear the downstream effect of our errors. To err is very human, and to forgive may well be divine, but not only that, it is also a remarkably compassionate human gesture.