by Niall Downey, author of
Oops! Why Things Go Wrong: Understanding and Controlling Error | 4 min read
It’s Not Your Fault
Society’s development has accelerated at warp speed over recent decades and shows no signs of slowing down. Unfortunately, our brains have had trouble keeping up and are trying to function in a highly complex, rapidly changing environment whilst still running on caveman software!
This dichotomy is the essence of what I explore in my book, Oops! Why Things Go Wrong. The mismatch between the fast-paced environment and our inability to respond appropriately results in errors inevitably occurring. This is merely an inconvenience in many areas, but in Safety Critical industries such as aviation and healthcare, it can literally mean life or death.
Your Good Health
I was sitting at the nurses’ station on a ward in a major Belfast hospital. The bed closest to me had the curtains pulled. The ‘crash’ team had just left and behind the curtains was an elderly lady who had just died from irrecoverable cardiac failure, precipitated by me prescribing her more intravenous fluids than her ailing heart was apparently able to handle. I had just killed my first patient!
My training as a doctor focused primarily on not making mistakes. They were considered unacceptable and something not to be discussed, especially if you hoped to progress up the career ladder. However, sticking our heads in the sand is not the answer. In developed countries, for example, it is estimated that around 10% of hospital admissions suffer an adverse event with around 5% of these causing or contributing to their death. Error is estimated to cost about 10% of a country’s healthcare budget despite up to 70% being considered preventable. In the UK alone, that’s over £15 billion!
When I jumped ship to retrain as an airline pilot, I was somewhat disorientated by a completely different approach to error. It was seen as inevitable and therefore something to be dealt with, not ashamed of. It took me quite a while to come to terms with this different mentality, but over time I realised what a valuable approach it was.
Again, the statistics are clear: total deaths globally in commercial jet aviation in 1977 numbered around 3000 people while currently figures are less than 1000 annually despite an almost tenfold increase in passenger numbers. Indeed, in 2017 the number of deaths globally was zero! This is due largely to our focus on Human Factors since the late 70s.
Twelve years ago I started to convey the lessons from aviation to a healthcare audience with limited success. Recently, however, the mindset seems to have changed. Staff appear more accepting of the inevitability of errors regardless of how hard they work. Patients too no longer expect their doctors to be perfect, but when mistakes do occur most want truthfulness, an apology, and signs that steps are being taken to avoid a recurrence. Healthcare administrators also need to play their part as currently a defensive stance means patients have no alternative but to lodge a complaint or even instigate legal action in order to get answers, which generally leads to a sub-optimal outcome for all involved.
What About Everyone Else?
Other industries are by no means immune from error. Agriculture, for instance has the highest mortality rate amongst workers in the UK and Ireland. UK figures show deaths consistently running at 20 times higher than other industry averages. It has been argued that poor political decision making led to huge variations in COVID-19 mortality rates from country to country. Could these errors have been avoided or at least mitigated?
Error has even become a commodity in recent times. Fake news sites have proliferated to the point where fact and fiction have become increasingly difficult to differentiate. This has been exploited by groups manipulating the information to influence everything from how citizens vote to what shampoo they use. Perhaps it’s time to teach people how to analyse information to try to separate the wheat from the chaff.
The criminal community though is hoping that doesn’t happen as they focus their efforts on, among other things, misleading unwary citizens into divulging sensitive information such as banking details to side-step online security measures. If caught, they may be relieved to know that our justice and policing systems are as error-strewn as other areas of society.
In short, we can add error to death and taxes on our list of inevitabilities in life.
So What Can We Do About It?
The good news is that the problem of error is, at least in part, solvable. Using the toolbox of tried and proven Error Management strategies, we can make major inroads to reduce its occurrence as well as its impact, greatly improving outcomes for us personally and society generally. The pace of change may have out-run our brain’s ability to manage successfully, but we can fight back. Given that technological developments show no sign of slowing down, it’s time we got started!
Oops! Why Things Go Wrong: Understanding and Controlling Error (£22.95; 312 pages; ISBN 9781739789268) by Niall Downey is published by The Liffey Press and available from Casemate UK.
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