Monday, July 25, 2016

The Error-prone Species



To Err is Human. Why?
I know, I am questioning one of the fundamental tenets of human society. This particular idea is so ingrained in us that we have devised a flurry of arguments to keep its support alive at all times, and under any circumstance. A few of them are:
1. Making mistakes teach us valuable lessons.
2. Mistakes teach us to be forgiving.
3. Mistakes help us let go of our fears.
4. Making mistakes is essential to living a life without regrets.
5. Mistakes help you grow as a person.
6. Mistakes can be fun.
7. Mistakes lead to success.
8. Mistakes serve as a warning.
9. Mistakes allow us to see how we are like others.
10. No human is perfect and so everyone makes mistakes.
We don’t stop here. Our understanding of errors has been enhanced by distinguishing between two types of cognitive tasks that may result in errors. The first type of task occurs when people engage in well-known, oft-repeated processes, such as driving to work or making a pot of coffee. Errors may occur while performing these tasks because of interruptions, fatigue, time pressure, anger, distraction, anxiety, fear, or boredom. By contrast, tasks that require problem solving are done more slowly and sequentially, are perceived as more difficult, and require conscious attention. Examples include making a differential diagnosis and readying several types of surgical equipment made by different manufacturers. Errors here are due to misinterpretation of the problem that must be solved and lack of knowledge. Keeping in mind these two different kinds of tasks is helpful to understanding the multiple reasons for errors and is the first step in preventing them.
We continue. Now we try to distinguish between different environmental conditions that can lead to errors. People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g., difficulty attending carefully to several things at once and generally poor computational ability, especially when tired).
There are many opportunities for individuals to prevent error. Some actions involve communicating clearly to other team members, requesting and giving feedback for all verbal orders; and being alert to “accidents waiting to happen.”  Other actions that include simplifying processes and standardizing protocols, developing and participating in multidisciplinary team training, and, being receptive to discussions about errors and near misses, are also in vogue.
However, large, complex problems require thoughtful, multifaceted responses by individuals, teams, and organizations. That is, preventing errors and improving safety require a systems approach to the design of processes, tasks, training, and conditions of work in order to modify the conditions that contribute to errors.
Designing for safety, which requires a commitment to safety, a thorough knowledge of the technical processes of care, an understanding of likely sources of error, and effective ways to reduce errors, is our present approach to this issue.
So much preparation is not needed, for any other form of life, to do things in the right way. What is the difference between humans and all other species? How is that we are very comfortable with the argument that no human is perfect, and, say, all dogs are perfect?
There is a big difference between humans and other species. Unlike other forms of life, humans tend to do everything in a style that is more than natural, and, though the mating season lasts throughout the year, there is no visible post mating agony. Putting two and two together, I think it is rather intuitive to conclude that humans need so much of style and preparation to occupy all the activities of life fully, such that, there is less time or space left for mating, and none for post mating agony. (This perhaps explains how, we happen to have many of our customs, ceremonies and codes centered around the human reproductive organs) And one dependable facet of every activity of life, which has the power to keep us engaged, happens to be, errors. Errors can provide a reason to keep us occupied, even when everything else fails.

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