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To extract a full account of the incident, remove blame and punishment on an organizational level from your retrospectives. You get there easier by reducing the fear and biases that creep in during the investigation of failures, and by choosing reconciliation and immunity over retribution.
Blame and biases — such as hindsight bias — give us a convenient story about what happened in any negative situation. To the extent that a story feels comfortable, we believe that it's true but when we get to that convenient point we stop learning.
Skipping the learning process alleviates t...
A timeline is an account of what happened by the people who were involved and impacted. Create a timeline with input from as many people from diverse points of view. With some training, anyone in the organization can do it.
A good timeline shows not just what happened, but serves as a refer...
Most companies conduct postmortems at a project’s end to analyze and outline the factors that contributed to its failure. But this reflection, examination and evaluation might not be as useful as most wait for failures to conduct them and stop the analysis once the guilty are identified.
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... specifically cognitive biases, are your unchecked tendencies to make decisions or take actions in an irrational way.
Instead of making decisions based on facts and data, you are more prone to base your decisions on unconscious errors that lead to a distorted judgment of the worl...
published 9 ideas
You can’t build software without encountering incidents – from critical bugs to full-blown outages, dealing with incidents are an inevitable part of the process.
As a result, you’ll find no shortage of articles telling you how to write a review – or as they’re commonly know...
published 9 ideas
The researchers devised a spectrum of hypothetical near misses based on real-life practice. Employees were asked to rank the likelihood that they would report the following near-miss scenarios, which become progressively more threatening to the patient:
❤️ Brainstash Inc.