Thoughts on Mistakes

• Humans will always make mistakes, for a variety of reasons (for example lack of experience, skill, concentration, understanding etc.)
• Mistakes are the best way to learn
• We should not have a culture of blame
• Mistakes are not caused by people, they are caused by failure of process.
• When a mistake occurs, the most important thing to do is to analyse what happened, and then change the process to prevent it happening again
  • basically keep asking ‘why’ until you get to the root cause
  • the changes might mean having a checklist, or adding a review/signoff stage, or using software permissions to enforce something