JOE_PODOLSKY@HP-PaloAlto-om4.om.hp.com wrote:
>
> There were two thought jogging articles in _The New York Times
> Magazine_ on June 15, 1997.
>
> The first is "A Bug by Any Other Name" by technology journalist
> James Gleick. In it, Gleick slams "Microspeak," the process of
> painting rosy word pictures that Microsoft has raised to a high
> art. In Microspeak, says Gleick, "bugs" are really "issues."
> "This could be a known issue or an intermittent issue. Then
> again, it could be a design side effect, undocumented behavior,
> or, perhaps, a technical glitch."
>
> ----snip---
> Gleick's article is light. He makes his point with a poke of
> irony. The second article is very different, very serious, in
> fact, heartbreaking. Written by Lisa Belkin, the article's
> title asks, "How Can We Save the Next Victim?" It's about
> medical mistakes, "bugs" that aren't annoying or funny or
> expensive, but fatal.
>
> It is the story of Jose Eric Martinez who died on August 2, 1996
> in Hermann Hospital in Houston because of a series of mistakes
> that resulted in the two-month-old infant getting a fatal
> overdose of medication. Documentation of the events is
> chilling, because the death was caused by intelligent people,
> carefully doing their jobs, within a system that failed. And,
> while the article revolves around the Martinez tragedy, Belkin
> brings in vignettes of other equally horrible incidents.
>
>-----snip----
> So, we have to take the next step: decide to get better, as
> measured by business results, from metrics specified by business
> managers. Then and only then can we turn inward and use our
> technology for sustaining those results and for leading our
> business colleagues toward the results we feel are possible.
>
> What are the linkages between our key processes and business
> results? What are the trends? What are the problems that we
> are seeing? Are we publicly discussing the problems in clear
> terms, not Microspeak, without worrying about blame? And, most
> important, rather than just living with the situations, are we
> determined to get better?
Joe, I really enjoyed your posting--and the articles you mentioned.
I think the harsh reality of errors is the cost involved in minimizing
them--the risk management factor.
I used to work with "casualty" models, years ago. For those of you who
aren't familiar with them, casualty models are tools used to determine the
number of combatants who will be killed or otherwise made unavailable
(wounded, missing, etc) for operations after a specific combat encounter.
Acceptable risk is what field commanders must consider, given the stakes
of the mission's objectives. Acceptable risk almost always includes
casualties.
In the pharmaceutical industry, similar acceptable risk is statistically
determined. There are x people allergic to y drug who may be disabled or
killed with its use, however there aren't enough x people to make the drug
(which is otherwise wonderful) be controlled to completely eliminate those
odds. The cost of eliminating risk was simply assessed too high by the
drug manufacturer.
Food processors can only have a statistically insignificant amount of
impurities in their food. Of course, the person who finds the half-mouse
in their canned soup is the statistical anomaly. C'est la vie! It simply
would make your soup prohibitively expensive to totally eliminate
impurities.
I don't have a solution--I'm simply sharing the harsh reality that
euphemisms soften. casualties, statistical anomalies, prohibitive costs.
Doc
-- Richard C. "Doc" Holloway Thresholds--Human Development and Networking for Learning Organizations LearnShop(tm) Creator and Facilitator P.O. Box 2361, Olympia, WA 98507 Phone: (360) 786-0925 Fax: (360) 709-4361 mailto:olypolys@nwrain.com"The familiar life horizon has been outgrown, the old concepts, ideals and emotional patterns no longer fit, the time for the passing of a threshold is at hand."
-Joseph Campbell
Learning-org -- An Internet Dialog on Learning Organizations For info: <rkarash@karash.com> -or- <http://world.std.com/~lo/>