Use PDSA thinking to turn near misses into tested operating improvements.
A near miss is not a story to forget. It is a system signal with unusually low damage. The PDSA Lens PDSA is a cycle for learning: Plan a theory, Do a small test or observation, Study the result, and Act by adjusting the process. The key difference from a casual lessons-learned chat is that PDSA asks for a prediction and a measure. It turns "be more careful" into "change this condition and see whether the error mode reduces." Why Near Misses Matter Utility work has high-consequence failure modes. Waiting for actual harm before learning is expensive and dangerous. A…
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