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System errors, human errors, and common sense

System errors, human errors, and common sense
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Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

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“It was a system failure.”

That’s what United Airlines CEO Oscar Munoz said in an interview with ABC News about the recent incident involving the violent removal of a seated passenger from a plane.

I’m not so sure.

I have blogged many times about the tendency of hospitals and other organizations to blame mistakes on systems when human error is often the real cause. Here are a few examples.

Delta Airlines allowed a nine-year-old boy to fly from Minneapolis to Las Vegas without a ticket or boarding pass. In the post, I pointed out that the system wasn’t the problem. Several humans failed to do their jobs in order for it to have happened.

A 16-year-old patient suffered complications after he was given 38 antibiotic pills by a nurse who failed to question the order. 38 pills? She should have questioned the order but put too much trust in the electronic medical record and its supposed infallibility.

I once worked at a hospital where every mistake was blamed on the system. Corrective actions to the system had to be developed through endless root cause analysis meetings. In a post called “System failure often really means someone made a mistake,” I discussed several papers which found most medical errors were caused humans, not systems.

Many people have missed the fact that the United flight from Chicago to Louisville was not simply overbooked. The problem arose when four members of a United crew who need to get to Louisville to staff a flight the following morning showed up at the airport. Every seat on what was the last flight to Louisville was already occupied by a ticketed passenger. Four people would have had to get off the plane in order to make room for the United employees.

No story to date has explained why these crew members needed to get to Louisville on such short notice. Was it because of a system problem, or did someone forget to book these four employees on an earlier flight? Were those employees late getting to the airport? It is hard to believe that the system was designed for the employees to assume there would be four empty seats for them on the last flight of the day to Louisville.

What about the gate agents? Reports say they had offered passengers $800 plus a hotel room to give up their seats. Some airlines have gone much higher. In 2016, United posted a profit of $2.3 billion. Was calling the airport police to forcibly remove a passenger their best option?

Since when are airport police authorized to drag a passenger who had not committed a crime through the aisle of a plane at the request of an airline? Apparently no officer thought to himself, “Should we do this?”

And now for the corrective action—Munoz said his company had not provided its front-line employees “with the proper tools, policies, and procedures that allow them to use their common sense.” He added, “This is on me. I have to fix that, and I think that’s something we can do.”

After many years of investigating the causes of surgical complications, I believe common sense cannot enabled by tools, policies, or procedures, nor can it be taught. Quite the contrary, one characteristic of common sense is recognizing when the right thing to do is to ignore the rules.

Predictions:

1. The United fiasco will be forgotten by the end of this month.
2. People who said they will never fly United again will do so when they need to go somewhere serviced only by United or when United’s fare is the cheapest.
3. United will experience another “system error” very soon.

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

Cartoon source: http://dilbert.com/

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