Operational mistakes are a given when the processes are dependent on human judgment. New staff, insufficient training, a lack of awareness, and flawed directions all played their part in setting up the window where mistakes were likely. In this case, a cascading series of decisions took a small “oops” into a big “oops”! The outcome was not something we could or would want to hide.
As we began the disclosure process, the need to know and understand what had happened, accurately and in detail became acute for several, myself included. The superficial answers might satisfy some, but the niggling fear that everything could repeat itself at any moment unless we fixed whatever the underlying problems were would not go away.
What happened and why?
As I look back, I do not think I understood how unusual our response was. For many, again myself included, mistakes are made, glanced at, and put aside. There is little or no willingness to be accountable for yesterday, it is always about tomorrow. The historical cliché reminding us that we will repeat history unless we learn from it is ignored. We are smarter, wiser, and more capable than the characters in the stories that gave birth to the cliché. Whatever you and I might think, the record suggests that we are the same as others across history. Unless we learn, and learn deeply, we will make and remake the same mistakes.
On this day, we were determined to dig deep. Nobody was going to be fired. There was no intent to humiliate those who had been a part of the broken processes. I think our truth and compassion filled intent opened a door to candor and honesty.
Two outcomes. First, there were fundamental flaws that needed to be addressed. Our fear of a repeat had morphed in a certainty that it would happen again unless things changed. Additionally, “what I solemnly swore I’d do that day when I was in so much trouble” (Psalm 66.14) included a resolution to always pursue lessons of truth, no matter how painful they might be.