Mistakes are inevitable. However, the natural assumption is that organizations try to learn how to prevent mistakes from recurring, especially in the wake of catastrophe. While changing processes and incorporating precautionary measures is usually the first response of a company aiming to recover from a major failure, many times, this learning wanes over time.
"Why do organizations forget what they learn, even when stakes are so high?" This is the question that drove Francisco Polidoro Jr., PhD, an associate professor at the McCombs School of Business at the University of Texas at Austin, along with fellow researchers to find out why some companies continue making the same serious errors over and over. Dr. Polidoro detailed his findings in the Harvard Business Review.
According to Dr. Polidoro, the occurrence of a serious error precipitates the learning cycle, motivating a company to emphasize safety as a top priority, identify the underlying cause of the problem and take corresponding corrective actions to improve its processes, structure and culture. "The problem is that these safety-related behaviors fade over time and other motivating forces come to the fore, gradually launching the seeds of the next error," he wrote.
Following a serious failure, an organization is under immense external pressure — from the public, customers and regulators — as well as internal pressures to learn from the mistake and prevent it from happening again. However, over time, that learning is gradually forgotten. External pressures are lessened as the media and public's attention moves on to the next thing, while internally, immediate success in preventing a similar failure produces a false sense of security, leading the organization to ease its focus on safety, according to Dr. Polidoro.
Additionally, other priorities, such as rolling out new products or cutting costs, emerge as more urgent.
Dr. Polidoro and his colleagues analyzed 146 pharmaceutical firms between 1997 and 2004 to obtain a qualitative understanding of the cycle between learning and forgetting after safety-based failures. They found that a serious drug error prompts a stronger focus on safety; the company conducts more expansive clinical trials and publishes more articles on corresponding results. At the same time, a serious drug error detracts from the company's innovation; the volume of new patent applications drops. However, both of these effects diminish over time, suggesting the safety focus dwindles and the innovation focus resumes in a cycle of learning and forgetting.
An important step in avoiding this cycle is being aware of the complacency trap — "A lull in the occurrence of serious, high-visibility mistakes should not be taken as a signal that a focus on safety is no longer necessary," Dr. Polidoro wrote.