Duke Medical Center offers online training module "Anatomy of an Error"

@Whatsthepont pointed me to this online training module from Duke University Medical Center. Entitled "Anatomy of an Error," the course intends to teach hospital employees about the types of error they can expect and show them how to reduce error and avoid catastrophic outcomes through human factors and well-designed processes.

This is a very important piece of evidence that error and mistake awareness is becoming more prevalent in complex environments, such as health care, where it is badly needed. The Duke module is a good step forward. That being said, I have some criticisms of the course, which I will cover in a future post. For the moment, let's share the Duke definition of an error, which is aligned with the definition of a mistake from the introduction to the book:

Dr. James Reason, a Professor of Psychology who has published extensively on the nature of human error, describes error as circumstances in which planned actions fail to achieve the desired outcome.

Our definition of a mistake is: an unexpected result proceeding from faulty judgment or inadequate knowledge.

The Duke module is a very useful introduction to error and how it works in complex environments. But don't view it as the complete story - there are some significant missing components that I will discuss this week.

Calculation error gives Moog synthesizer its signature sound

Bill Hemsath, one of the engineers of the original Minimoog synthesizer, on why it had such a distinctive sound.

Our instrument had punch to it because we inadvertently overdrove the filter like crazy. Jim Scott did the filter and voltage controlled amplifiers. He made a calculation error, and he overdrove the filters by 10, 12, 15 dB, something like that. And nobody knew that until a month or two after we started in production. And everyone said, "Leave it alone!"

Hat tip New York Times.

In competitive sailing, fix error first, then discuss

Some good advice from Union Square Ventures' Albert Wenger, garnered from his experience in the 2012 Vineyard sailboat race. This is among six valuable lessons he learned:

Recover quickly from errors. When something goes wrong on a boat, there is no time to go sulking. Instead the problem needs to be fixed or it will generally get much worse. There is time to discuss what went wrong and how to avoid it once the problem has been fixed. Put differently, a moment of crisis is not a good time for the team to start questioning each other. That too is a good way to operate as a team at work.

Steven Johnson: "We have a tendency to dismiss error" when we shouldn't

This is from Steven Johnson's great book "Where Good Ideas Come From: The Natural History of Innovation." There is a chapter entitled "Error" and describes/reinforces many of the points we've illustrated on this site. I highly recommend the book.

The trouble with error is that we have the tendency to dismiss it. When Kevin Dunbar analyzed the data from his in vivo studies of microbiology labs, one of his most remarkable findings was just how many experiments produced results that were generally unexpected. More than half the data collected by the researchers deviated significantly from what they had predicted they would find. Dunbar found that the scientists tended to treat these surprising outcomes as the result of flaws in their experimental method: some kind of contamination of the original tissue perhaps, or a mechanical malfunction, or an error at the data-processing phase. They assumed the result was noise, not signal. [Kindle location 1658]

In other words, many projects don't deliver the expected results; i.e., they are mistakes. And yet a lot of good comes from this. Johnson writes that there is much more "signal" in these mistakes than we expect, and we tend to overlook them or attribute them to our own errors, not some other factors that may be meaningful. This is yet another reason to revisit mistakes for learning. Yes, you will find things you did wrong, but you may also discover something entirely new.

Renny Gleeson: the 404 error page is an opportunity to engage with users

In this TED talk, Renny Gleeson discusses the HTML 404 error (page not found), and how companies have creatively designed their version of this error page to build connection with their users. Says Gleeson, "A simple mistake should remind me of why I love you."

Kathryn Schulz explains how believing we're right, even if we're not - makes us humans

Kathryn Schulz, author of "Being Wrong: Adventures in the Margin of Error," discusses how our propensity to create explanations for things, most of which turn out to be incorrect, is not a disability, but rather the source of our human uniqueness.

My favorite line is when Schulz quotes from Ira Glass, describing the theme of his show, "This American Life": "I thought this one thing was going to happen, and something else happened instead."