terça-feira, março 20, 2007

Aprender com os erros

"O Erro em Medicina"

Foi da introdução deste livro, da autoria de José Fragata e Luís Martins, que me lembrei quando li e encadeei estes textos.

Primeiro este número:

“Usually doctors are right, but conservatively about 15 percent of all people are misdiagnosed. Some experts think it’s as high as 20 to 25 percent,” Groopman tells Steve Inskeep. “And in half of those cases, there is serious injury or even death to the patient.”…Errors in thinking: We use shortcuts. Most doctors, within the first 18 seconds of seeing a patient, will interrupt him telling his story and also generate an idea in his mind [of] what’s wrong. And too often, we make what’s called an anchoring mistake - we fix on that snap judgment. aqui.

Depois este texto de Russell Ackoff sobre o pensamento sistémico, aqui, onde se pode ler:

"When, on the completion of our schooling, we enter an employing organization, which also makes it clear that mistakes are a bad thing and that they will be held against us."
...
"There is nothing wrong in making a mistake, but if you ever make the same mistake twice you probably won't be here the next year." He had it right: mistakes will be forgiven if we learn from them.
We cannot learn from doing anything right. We already know how to do it. Of course we may get confirmation of what we already know and this has some value, but it is not learning. We can learn from mistakes if we identify and correct them.
Therefore, organizations and individuals that never admit to a mistake never learn anything. Organizations and individuals that always transfer responsibility for their mistakes to others also avoid learning."

Temos de aprender com os erros, é fundamental aprender com os erros. Para isso é preciso encarar os erros como produtos naturais de um sistema, para isso é preciso ter instalados mecanismos de feedback, mecanismos emissores de sinais, para isso é preciso analisar esses sinais com ferramentas adequadas, para isso é preciso um clima de abertura e discussão que fomente a liberdade de expressão, para isso é preciso ser assertivo o suficiente para mexer e mudar o que tem de ser mudado no sistema.

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