Preoccupation with Failure

By Andre Harris, MD, chief medical officer, Miami Valley Hospital

Over the past several years, I have consciously shifted the way I approach my work, as well as life in general. Like many of us, I was trained to see things as right or wrong. Black or white. The gray areas were details for someone else to sort out. That kind of binary thinking leaves little room for curiosity. And without curiosity, learning stops.

Curiosity pushes us to ask why things turned out the way they did. It pushes us to gather all the information before making a judgment. Nowhere is this more important than in how we respond to complications and adverse outcomes in medicine.

Physicians, by the nature of our training, are focused on doing things right. We train relentlessly for technical excellence. We memorize protocols. We rely on evidence-based pathways. But what happens when failure arrives? The patient who develops a postoperative complication. The diagnosis that was delayed. The shoulder dystocia that results in a permanent brachial plexus injury. These events stay with us. They should.

The essential question is not, “Was this a known complication?” The essential question is, “Why did this happen to my patient?”

This idea is foundational to the high reliability principle known as preoccupation with failure. It is not pessimism. It is vigilance. It is the understanding that even when things are going well, risk is always present. And when failure occurs, our responsibility is not to explain it away, but to understand it deeply.

The concept of failure to rescue illustrates this perfectly. First described by Silber in 1992, the work examined patients undergoing routine procedures, such as laparoscopic cholecystectomy, who developed complications and ultimately died.

That scenario embodies preoccupation with failure. It demands that we move beyond labeling events as “unfortunate,” “rare,” or “expected risks.” Instead, it asks us to study the conditions, processes, handoffs, and signals that failed our patients.

Failure, by definition, is the inability to meet an intended objective shortfall in normal function. In healthcare, failure often carries emotional weight: shame, grief, frustration, even fear. Those responses are human. But when they cause us to avoid scrutiny, we miss our greatest opportunities to improve. 

As a growing Academic Medical Center, our challenge is not to run from failure, but to lean into it constructively. Each adverse outcome is a chance to build stronger guardrails. To add clearer hazard signs. To install stoplights that give our teams permission to stop the line when something doesn’t feel right.

Preoccupation with failure is a leadership responsibility. It requires psychological safety so teams feel comfortable raising concerns early. It requires humility to recognize that experience alone does not protect us from error. And it requires discipline to continuously ask, “Where could this fail again?” even after a good outcome. 

When we embrace this mindset, failure becomes more than an event. It becomes a teacher. And when we learn systematically, transparently, and together, we move closer to delivering safe, reliable care, every patient, every time.

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