The Fallacies of Work as Imagined

When I was growing up as a hospital pharmacist, the talk of patient safety was route cause analysis. When an error happens, find out what went wrong and take action to prevent it from happening again. Classic Swiss cheese model stuff. A lot of the time this ended up in proliferation of protocols and policies to try and ensure everyone knew the right thing to do and make the system safer. That and an overabundance of laminated warning signs blue tacked all over the hospital.

There’s a new approach to safety (not exclusive to healthcare) that shifts the focus away from controlling the system to reduce human error (work as imagined) toward designing systems that make it more likely that humans will be able to perform their work effectively. That’s what this presentation is about.

You can see the presentation here

and the slides here

After sharing this last week I read the following which I think complements this pretty well. It’s an excerpt from this book

We have three rules here at Netscape. The first rule is if you see a snake, don’e call committees, don’t call your buddies, don’t form a team, don’t get a meeting together, just kill the snake.
The second rule is don’t go back and play with dead snakes. Too many people waste too much time on decisions that have already been made.
And the third rule of snakes is: all opportunities start out looking like snakes.

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