“We have the same safety issues as twenty years ago. Depressing.”
That’s what the COO of a large healthcare system told me after we reviewed the most recent patient and employee safety incidents.
It wasn’t said with anger.
It was said with fatigue.
The kind of fatigue that comes from firefighting the same problems over and over again—treating symptoms, not causes; solving the urgent, not the important. In that moment, I could sense not only disappointment but also a deep sense of resignation: We’ve done so much work, and yet… we are still here.
This kind of frustration is not unique. Across industries—but especially in healthcare—I have met many leaders and caregivers who carry the same exhaustion. They are committed, they care deeply, and yet the same types of incidents keep recurring. Falls. Medication errors. Equipment issues. Communication breakdowns. It’s as if the organization is living in a loop of déjà vu, where each “new” problem feels eerily familiar.
When we stepped back and looked together at their safety log, I asked a few simple questions.
Was the origin of each issue identified?
Was the root cause found and validated?
Were countermeasures tested and implemented?
Was problem solving done without blame—or self-blame?
Silence.
That silence said a lot.
Because behind every “same issue” is usually the same system of thinking.
Until leaders create space for real problem-solving—rooted in humility, curiosity, and learning—history keeps repeating itself.
Safety isn’t just about preventing harm.
It’s about preventing repetition.
Most healthcare organizations have safety reporting systems. They track incidents, collect data, conduct reviews, and sometimes even hold safety huddles to discuss findings. These are valuable elements—but they are not, by themselves, a safety system.
A system for safety should enable people at every level to identify, analyze, and address the conditions that create risk before harm occurs—and to learn from the events that do happen so they do not repeat.
Instead, what we often see is a cycle of reaction.
Something goes wrong.
An incident report is filed.
A quick fix is applied.
A reminder email is sent.
A training module is added.
Then, for a while, things quiet down—until the same issue reappears in a slightly different form.
This reactive loop is fueled by pressure: pressure to move quickly, pressure to demonstrate action, pressure to show that something has been done. Yet the pressure to act fast often overrides the need to learn deeply.
The result is that we solve the visible symptom, but not the underlying system behavior that produced it.
The key to breaking the cycle lies in the quality of problem solving.
In too many organizations, problem solving is viewed as an event—something to do after an incident. But in organizations that truly advance safety, problem solving is a habit and a discipline. It is part of the daily management system.
When a problem arises, they don’t rush to fix it. They slow down to understand it.
They ask:
What exactly happened?
What conditions allowed it to happen?
What process failed—or was missing entirely?
What did we assume that turned out not to be true?
How can we test potential countermeasures safely and learn from them?
That process takes time, but it saves time in the long run. It replaces repeated firefighting with cumulative learning.
A powerful sign that an organization is advancing in its problem-solving maturity is when frontline teams—not just managers—are equipped and supported to investigate, experiment, and learn in real time. This does not mean burdening caregivers with more tasks; it means empowering them with better tools and systems for thinking.
When every person learns to see and respond to problems scientifically, the organization starts to grow its capacity to learn.
Leaders play a critical role in this transformation. They set the tone, create the conditions, and reinforce the behaviors that define the culture of safety.
Many leaders, understandably, feel immense pressure to respond to safety events. Families, staff, boards, and regulators demand answers and accountability. But speed without understanding can be counterproductive.
A leader’s greatest contribution in these moments is not to have all the answers—but to model how to learn.
That begins with humility. The humility to say, “I don’t know yet.” The curiosity to ask, “What can we learn from this?” The patience to create psychological safety so others can speak honestly about what happened.
When a nurse fears punishment for an error, or when a physician feels the need to defend rather than reflect, the opportunity to learn is lost. Likewise, when a leader blames themselves and rushes into corrective action without reflection, the system remains unchanged.
The essence of leadership in safety is not control—it is curiosity.
As Dr. Don Berwick once said, “Every system is perfectly designed to get the results it gets.”
If we want different results, we must first learn to see the system as it is.
In Lean thinking, problems that reappear signal a deeper issue: the process has not changed, or the organization has not learned from the prior event.
There are several common reasons for recurrence:
Lack of root cause clarity.
Many investigations stop at the first “why.” We attribute a fall to “staff not following protocol” or a delay to “communication failure.” But these are symptoms, not causes. The real causes are in the systems that make errors likely—staffing levels, layout, workflow design, unclear standards, or conflicting priorities.
Countermeasures without testing.
Too often, corrective actions are implemented without experimentation. They are rolled out broadly based on assumption, not validated learning. Without testing, we don’t know whether a countermeasure actually changes the conditions that led to the problem.
Failure to capture and spread learning.
Even when a team discovers a root cause and implements a solution, that learning may stay local. Without a mechanism to share and standardize improvements, other units continue to face the same issue.
Culture of blame or self-blame.
When people associate problem solving with criticism or failure, they will avoid it. The result is superficial learning at best.
Leadership attention on results, not process.
Safety outcomes are lagging indicators. By the time an incident occurs, it’s already too late. True prevention requires attention to leading indicators—how consistently processes are followed, how rapidly problems are surfaced, and how quickly teams learn.
Each of these patterns reflects a gap in thinking, not just a gap in performance.
Changing the system means changing the way people see, think, and act in relation to problems.
Many organizations claim that “safety is our top priority.” It’s a well-intentioned statement, but priorities can change. Systems endure.
A true safety culture doesn’t depend on priorities—it depends on design.
That design is built into daily routines:
How leaders round.
How teams huddle.
How data is reviewed.
How problems are visualized and addressed.
How learning is captured and shared.
In organizations that have achieved sustained safety improvement, these routines form an interconnected system. Problems are not escalated for punishment—they are escalated for learning.
The daily management system becomes a learning engine. Each day, teams reflect on what went well, what didn’t, and what needs to be tested next.
Leaders ask, “What did you learn today?” not “Did you meet your target?”
Over time, this discipline transforms not just safety outcomes but organizational culture. People begin to see problems as treasures, not threats.
It’s important to acknowledge that safety work is deeply emotional. Every incident touches lives. Every story carries weight.
When a caregiver is involved in an event, they experience guilt, fear, and sadness. When a patient is harmed, entire teams feel the impact. Leaders often carry invisible emotional burdens—they must support their people, face external scrutiny, and hold themselves accountable.
That’s why a system for safety must also be a system for compassion.
Blameless problem solving is not about avoiding accountability—it’s about enabling responsibility. It creates the psychological safety necessary for truth to emerge.
When leaders respond with empathy and curiosity—asking what happened instead of who is at fault—they make it possible for learning to occur.
And learning is what prevents repetition.
One of the most powerful yet underused tools in safety improvement is reflection.
After-action reviews, huddles, and learning sessions are opportunities to pause and ask:
What did we expect to happen?
What actually happened?
What surprised us?
What will we do differently next time?
This reflective discipline transforms events into sources of learning rather than frustration.
At first, it may feel slow. But over time, it builds organizational memory and wisdom.
Without reflection, experience alone does not teach us much. With reflection, even painful experiences become teachers.
When the COO said, “We have the same safety issues as twenty years ago,” I could sense the fatigue in his voice. But fatigue, in many ways, is a sign of caring. You don’t feel tired of something you don’t care about.
The challenge—and the opportunity—is to turn that fatigue into fuel for change.
That requires a mindset shift: from reacting to incidents to learning from systems; from punishing error to understanding behavior; from temporary fixes to sustainable learning.
It also requires leaders to build structures that make learning visible. A daily management system where safety metrics are reviewed alongside process indicators. A problem-solving framework that emphasizes experimentation. A leadership routine that reinforces curiosity and reflection.
When people see that problems lead to learning—and that learning leads to prevention—they regain hope.
They see progress, not just problems.
At its core, safety is not measured by the absence of harm—it’s measured by the presence of learning.
An organization that never reports incidents may not be safe; it may simply be silent.
An organization that reports, reflects, and learns from every issue is building true safety capability.
The ultimate goal is not just to reduce incidents—it’s to increase the organization’s ability to learn faster than it fails.
That is what turns repetition into resilience.
As I left that conversation with the COO, I thought about the power of simple questions.
Was the origin of each issue identified?
Was the root cause found and validated?
Were countermeasures tested and implemented?
Was problem solving done without blame or self-blame?
These are not technical questions. They are leadership questions.
They remind us that safety is not a department, not a dashboard, not a slogan—it’s a way of thinking and leading.
And when leaders create space for that kind of thinking—humble, curious, and disciplined—the same problems no longer return.
Because safety, at its best, is not just about preventing harm.
It’s about preventing repetition.