Swiss Cheese Or Bad Apple

I was recently listening Dr. Anthony Mazzarelli, co-president of Cooper University Health Care and fill-in radio talk show host of the Smerconish Program on POTUS, Sirius/XM. Dr. Mazz. said that his hospital's approach to confronting errors is swiss cheese as opposed to bad apples.

The conversation centered around the recent assassination attempt of a presidential candidate. Mazz said that one issue in the aftermath of the shooting, like so many other aspects of our society, is that people started looking for "the bad apple." One person who we could pin the blame on. Was it the now-unemployed head of the Secret Service? Was it an officer who should have covered the roof where the shooter was perched? The right answer is yes ... and no.

In the case of the assassination attempt, a 20-year-old kid had to fly a drone over the site for reconnaissance days before the event, acquire the weapon, gain access to the event site with a weapon, climb to the roof, and take the shots. There were several points along the way that the issue could have been stopped. Looking for ONE bad apple doesn't reduce the likelihood of the issue repeating itself in the future.

the truth is that most all significant errors are system failures, not failures of an individual. To prevent repeated issues, you need to find the holes in the system ... like layers of swiss cheese. The more layers you have, the more holes you cover-up.

It's easy to place blame on one thing or person, it is work to plug the system holes. Next time something goes wrong at the job or in your life, resist the urge to find the "bad apple" easy fix and look to cover the holes in the system:

1. Reverse engineer the problem as far back as you can take it

2. Analyze all of the steps

3. Were established processes followed?

4. Do new processes need to be established?

5. Did you actually get lucky?!? Could the system have broken down worse?

6. What new layers of "swiss cheese" do you need to add to plug the holes and avoid the issue in the future?