Bite‑sized knowledgeto upgrade
your career
to upgrade
Ideas from books, articles & podcasts.
Achieving Closure
- Determine and rank the steps that should be taken to change the conditions that brought the incident in the first place.
- To keep the learning review focused, prioritize and discuss these action items in separate follow-up meetings with the relevant people.
- The facilitator must publish the learning review write-up as widely as possible. Both successes and failures should become part of institutional memory.
- If the incident negatively impacted people, consider using the 3 Rs to structure the writeup. The Rs stand for ‘Regret, Reason, and Remedy’ as it provides a straightforward formula for a meaningful, satisfying apology.
2
STASHED IN:
89
published ideas from this article:
MORE IDEAS FROM THE SAME ARTICLE
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...
- Repeatedly remind your team that they’re part of a learning organization to make them focus on learning.
- Remind your people that you are all operating within complex systems, thus failures can be unpredictable.
- Failure is a normal part of the functioning of complex systems.
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.
Fa...
MORE LIKE THIS
... 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...
STASHED IN:
179
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...
3
STASHED IN:
4
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:
- Could have happened
STASHED IN:
5
published 2 ideas
❤️ Brainstash Inc.