“You can either learn or blame, you can’t do both.”

Dr George Douros

How is that blame occurs?

How is that blame occurs?

How do we learn instead of blame?

How do we learn instead of blame?• LOCAL RATIONALITY PRINCIPLE

• People come to work to do the right thing.• The decisions they make at the are dependent on their focus of attention,

their knowledge and their goals and seemed like the right decision at the time.

How do we learn instead of blame?• LOCAL RATIONALITY PRINCIPLE

• People come to work to do the right thing.• The decisions they make at the are dependent on their focus of attention,

their knowledge and their goals and seemed like the right decision at the time.

• Use counterfactual realities PROSPECTIVELY, not retrospectively.• Rather than using ‘should have’ to retrospectively blame people, use it to

design your systems to make ‘should have’ more likely in the future.

So, what am I doing about this?

So, what am I doing about this?• Education: human error, systems thinking, safety sciences, just

culture, incident analysis, formal safety process• Tools and logistics• Training…

So, what am I doing about this?• Education: human error, systems thinking, safety sciences, just

culture, incident analysis, formal safety process• Tools and logistics• Training…

So, what can you do about this?

So, what can you do about this?• Learn about error, systems thinking, safety sciences, just culture • Do an incident investigation course• Do a simulation facilitators course• Get another facilitator to give you feedback • Film yourself for feedback• Build a community of M&M facilitators – hospital/college/CEC

“You can either learn or blame, you can’t do both.”

george.douros@gmail.com