House keys and the inevitability of human error

It always saddens me when a medical mistake is reported in the media, and the immediate reaction of so many people is: “Someone that careless and incompetent should be fired. There is absolutely no excuse for hurting a patient by omitting such a basic step as calculating the right dose / making sure you have the right patient / checking for allergies / etc… ”

My immediate response to this is always: “Have you ever locked yourself out of your house?” Human beings make mistakes. Human beings sometimes omit basic, crucial steps from tasks they supposedly have mastered. We make small, stupid, high-consequence mistakes so predictably, so inevitably that an entire industry (locksmithing) is dedicated to undoing the small, stupid, high-consequence mistake of not ensuring we have our keys when and where we need them.

The keys analogy is actually a great way to think about… Continue reading →