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Complex Failure
I define complex failure as a failure with multiple causes. It’s a kind of perfect storm where multiple factors come together in just the wrong way to produce an undesired outcome. The global pandemic supply-chain breakdown was a complex failure. It had to do with many, many things, including workers not being able to come to work because they were ill, including weather patterns, including government leaders’ decisions.
Complex failures, like any failure, give us an opportunity to learn. And the most important learning, or the goal of the learning, is to prevent that particular kind of failure from ever happening a second time. The silver lining of complex failures is that all you have to do is catch and correct one of the factors to avert the failure. So they give us lots of complexity, but in so doing, they give us lots of opportunity to prevent them.
Attending to Ambiguous Threats
Many complex failures could have been avoided if people were willing to pay attention to and speak up quickly about what I call ambiguous threats. So an ambiguous threat is any small signal that might, but also might not, signify serious harm. So an ambiguous threat might be just that little thing that could be off, or it could be fine. As soon as someone notices something that they wonder about, it opens what I call a recovery window where you have this opportunity to potentially prevent a complex failure.
A great example of a complex failure was when a nine-year-old boy named Matthew, a hospitalized patient, received an overdose of morphine. Now, fortunately, the overdose was caught and corrected in time to save his life. So what happened? Did a single person make a mistake and lead to that outcome? No. In fact, I counted eight different small process deviations that if any one of them hadn’t happened, the overdose wouldn’t have happened. So there was the concentration of the medication on the cassette was folded over in such a way that made it hard to read. It was in a dark corner of the room, exacerbating the problem. There was a brand new nurse just out of training who was in charge of the patient at that moment. The patient was in a floor that didn’t usually take care of patients with that particular condition.
A recovery window for avoiding that failure, that overdose, started the moment the patient was wheeled to a floor which was not full of experts that would normally take care of a patient like this. So that was the moment where people should have realized, “Okay, this is unusual. This patient just came from surgery. We don’t usually see patients just out of surgery, so we’re going to have to double and triple check everything just to make sure that we’ve got this right. This is new territory for us.”
More often than not, people squander the recovery window because no one spoke up about the ambiguous threat or because they just assumed it’s probably nothing. And we have to get in the habit of speaking up about them, inquiring into them. Hmm, what’s that signal mean? Should we just take a look at it and see what we can learn, versus the very normal human response of ignoring them until we’re more sure that there’s a problem. So we have a natural tendency to downplay ambiguous threats. Cognitively, we easily tune them out. Interpersonally, we’re embarrassed to mention them. Organizationally, they don’t rise to the level of deserving our attention. So we downplay or tune out the ambiguous threats and thereby miss valuable opportunities to prevent many complex failures.
Prevention Strategies
The most important capabilities you need to prevent complex failures are the ability to size up a context for its failure potential. Just being aware that you are in a context with a lot of complexity, a lot of interacting parts, where things could go wrong, that increases the sort of vigilance that you will bring to that context which helps you detect things that might be off.
The second thing is to build and reinforce a social environment of psychological safety. People know that they’re welcome to speak quickly, early and often with even the most tentative of concerns. That’s absolutely essential for preventing complex failures. And then finally, it’s the behavior of catching and correcting errors, being on a treasure hunt for errors, looking to see the small and large things that might be off or might be risk factors, and getting out ahead of them rather than waiting until it’s too late.