Does anyone know any great management books on this subject?
The most memorable example was at a hospital, nurses would occasionally pick up the wrong vial. They always noticed before injecting, but there were lots of close calls that didn’t get tracked anywhere. Once they started tracking that as a leading indicator, it became pretty obvious that the vials needed a better design to prevent even the possibility of grabbing the wrong one. Also, if the hospital never realized this problem and someone got hurt, they would’ve ended up with a much worse solution like “double check really close”
Not a management book per se, but Working Backwards popularised an Amazon approach of thinking about the organisation in terms of mechanisms. You might find that useful.
I’ve always wanted to dig into Scarlet Ink, Dave Anderson’s blog, but never have, and I suspect it’ll be quite useful for you too.
This happens in organizations that become over reliant on metrics and indicators of success/failure instead of recognizing that these are fuzzy concepts and indicators are just that... indications, not answers.