What a fractured shoulder taught me about Quality
A few weeks ago, I learned a powerful lesson about quality — the hard way.
It had been drizzling, it was dark, the ground was uneven with various service covers on the footpath, and my weakened ankle from a previous trip gave way. One step later, I was sitting on the footpath, face down, with a fractured shoulder and a bruised ego.
As I sat there, my quality management brain started to kick in. What went wrong? What could have prevented it? And how often do we see the same chain of small issues leading to big problems at work? I’ve written so much about quality in the past. Events like these help to reinforce some great quality management lessons!
1. Risk management: seeing the whole picture
Each factor on its own seemed low risk: light rain, a slightly uneven path, a sore ankle. Together, they formed the perfect conditions for failure.
In quality systems, risk often hides in combinations rather than single points of weakness.
2. Preventive action: acting before the fall
A slower pace, a safer route, or even a walking stick could have made all the difference. (Although I’m not sure about the walking stick option of preventative action. I do have an image to protect 😉 )
Prevention is rarely dramatic, but it is always cheaper than correction.
3. Corrective action: finding the real causes
The injury was the outcome, not the root cause.
Behind it were contributing factors: physical weakness, environmental conditions, and inattention.
True corrective action means digging beyond the symptom to find what really drives failure. I’m definitely more careful now in less than optimal conditions! And I’ll be starting some yoga sessions now I am out of a sling.
4. System thinking: nothing happens in isolation
Walking safely relies on physical balance, environmental awareness, and decision-making. These are interconnected processes that all matter.
Quality systems work the same way. When one element changes, the rest must adjust.
5. Continuous improvement: learning from the fall
Recovery brings reflection. Stronger footwear, more care, and better awareness.
In an organisation, each incident is a data point for improvement. The key is to keep feeding lessons back into the system.
6. Human factors and competence
Even lifelong “experts” in walking make mistakes.
Confidence can breed complacency. Maintaining competence requires conscious awareness and ongoing attention.
7. Resilience: recovering with strength
Healing a shoulder takes time and patience.
So does rebuilding a process or culture after a setback. It can be slow and painful at the beginning.
Quality isn’t only about avoiding failure; it’s also about how we respond when things go wrong.
8. Design and environment: making it hard to fail
A safer path design or better surface texture might have prevented my fall. (Calling all in the MAS Family who do slip testing- there is a surface in northern Sydney in need of your expertise!)
I inspected the “scene of the crime” when I returned to the area 7 weeks later and was surprised at how poorly constructed and maintained the surface was.
Likewise, well-designed systems anticipate human error and make the right action the easiest one to take.
Quality management is never just about systems or standards, like ISO 17025, ISO 15189 or ISO 9001. It is about people — how we think, how we act, and how we learn.
Every fall, every failure, every small stumble is an opportunity to strengthen the way we manage risk, improvement, and resilience. The key is to keep walking, but a little wiser each time.
If this reflection resonates with you, share it with a colleague or bring it up at your next team meeting.
Quality improvement often begins with a single story. And a shared reminder that even experts can trip up now and then. What quality management lessons are lurking in your world?