Having no reports doesn't necessarily mean no incidents

It is common sense for any one who studies human errors that having no reports is not a good sign. Because to err is human, it doesn't necessarily mean no incident at all, rather just they are unnoticed or even worse, people are reluctant to report the incidents they do have.

The most likely reason for not reporting is: they are too busy or too tired to do so.

It is the case with me, too.

Working full-time, doing a postgraduate course, starting a family business, doing some volunteers and taking care of family, I wish I had 72 hours a day!

So I really needed a break.

As the postgraduate course is winding down and the family business is taking some shape, I am regaining control on my time. It was hard to catch up with the people who are already in some leading positions among health professionals. I realised medicine is an activity of human treating human, even it is expected to be expanded more into cyberspace.

He aha te mea nui o te ao? He tāngata! He tāngata! He tāngata!
What is the most important thing in the world? It is people! It is people! It is people!

I would like to conclude this entry by a small incident our family had the other day.

It was when we visited North Head for a picnic. It was a sunny holiday afternoon and we enjoyed tea and exploring tunnels and a natural cave. On the way home we dropped in on a supermarket for food to cook for the dinner. After shopping around we came back to our station wagon and open the rear hatch to find a Thermos flask without its cap!

We hurried home and stored chilled/frozen foods then my wife and children went off for North Head again. I had a meeting that evening which I had to conduct so I couldn't join the search.

To my great relief when I checked my mobile phone during the coffee break I found this photo message:

You should stop and think if you get stuck

Reported Incident Severity Level: MAJOR

My wife and I are cultivating flat mushrooms with used tea bags in our house. Originally it started with an all-in-one kit with specially prepared wood chips and spores. Then, we have been continuing on with tea bags culture bed as recommended in the instructions of the kit.

It requires a lot of used tea bags for each batch.  To prevent them got moldy, we store them in a plastic bag in the freezer of the refrigerator until we have enough of them. As more and more tea bags are stored in the freezer, they eventually get stuck when the freezer is opened.

This happened this evening and I was in a harry to unblock them when I forced the freezer box to slide out and pinched my finger which I had stuck into the teabag. My middle finger still hurts even after I had been cooling it with running water for a considerable time.

I should have stopped and thought and took a safer way like taking away the frozen tea bags one by one to unblock.

Actual Incident Severity Level: MAJOR
Root Cause: unsafe procedure

Maybe I need some stretch of the No. 8 Wire

Reported Incident Severity Level: MAJOR

Yesterday morning, when I drove to work, it was stormy in Auckland. I used an umbrella while I was walking from the car park to the office building. I headed to the back door of the building as it was a short path. Unfortunately it was still locked and I started to walk around the adjoining building to the front door of the main building.

Then, whoosh!

A sudden violent gust destroyed my umbrella. It was now useless and I was soaked while walking around to the entrance.

I thought that it was beyond repair and a write-off but a closer look revealed that it could be repaired somehow, maybe with some stretch of the No.8 Wire. Anyway, we should be careful when we are forced to change the course of our actions. That is a time more likely for us to be caught by the unexpected.

Actual Incident Severity Level: MINOR
Root Cause: slip of attention

Troubles in Getting My Voice Heard by My MacBook

Reported Incident Severity Level: MINOR

I am using an early version of Intel-based MacBook. It has a built-in microphone and a webcam suitable for video chat. It also has a headphone jack and an audio input port.

At the online course of the university I took last year required a Skype interview as part of its end of the course test. The lecturer recommended to use a headset instead of the built-in mic and speaker while communication over Skype and I purchased one. During the interview, the lecturer told me that the mic of headset didn't seem working so well but we managed to complete it. I have not been used the headset since then. So I forgot about it.

Recently, I found something was wrong when I tried to record my song in DTM software using the mic of the headset. When I looked into the screen the sound level bar responded but once I sit back in the chair and started singing the bar didn't pick up any signal.

I believed the mic input should be switched from built-in one to headset one, but it was not true. After searched around over the net, I learned that my MacBook's audio input port can't supply power to the headset mic. It is a plain line-in audio port. What I had been thinking as the voice through the headset mic was actually the sound picked by the built-in mic.

I have an old small battery powered mixer which has a plug-in power mic port. So I connected it between the mic jack of the headset and the Mac's line-in port. Then I tested. Still the headset mic didn't work. I thought the mixer was broken and purchased a tiny USB headset adaptor.

It was after I connected the headset to the adopter, I noticed the mic switch of the headset had not turned on. I still need the mixer anyway as MacBook doesn't have a plug-in power mic port but I didn't have to buy the USB headset adaptor.

Actual Incident Severity Level: MODERATE
Root Cause: lack of knowledge/insufficient prior check

The First Fire Drill in the New Office Location

Reported Incident Severity Level: MINOR

Yesterday, we had the first fire drill since our department was moved into the current building. I have been the unit fire warden for the department for years. So I had been familiar with the procedures of fire evacuation processes.

But, as it turned out, it was with the previous building, but not with the current one.

Of course, I went though the emergency information kit on the day we moved. However, the familiarity with the same procedures in old situations somehow prevented me from fully understanding those in the new circumstances.

Fortunately, I could pick up what I had missed out through physically moving about and identifying every bits and pieces of the procedures in the first drill. We are now better prepared, I hope. I thought such an on-site practice is vital to shake off the false assumption that everything would be the same as the situations we had been accustomed to but actually already changed in some ways.

Actual Incident Severity Level: SERIOUS
Root Cause: inappropriate application of old experience to new circumstances

Blog Title Changed

Reported Incident Severity Level: SERIOUS

As a job, I am dealing with medical errors by maintaining records of them and reporting to the people concerned. My own personality is quite fit for this job, not because I am a perfect person without errors, but because I have learned in a very hard way that human errors are inevitable - including mine.

After some inactive blogging months, it came to my mind that it would be useful for me, and maybe for some of the people out there, if I record my funny mistakes in the daily life and the lessons learned from them.

That is why now this blog has the new title, description and address with a new format.

Actual Incident Severity Level: MINOR
Root Cause: a change of minds

No nuke Japan - for the moment

Last weekend, the only nuclear reactor that had been operating in Japan was shut down for inspections. For the first time in 42 years, the electricity generated in Japan went nuclear free.

From the fear of the impact on already fragile Japanese economy and the soaring demand in the scorching summer soon coming, quite a few people are crying for immediate reboot of at least some of 50 reactors remaining after the 4 severely damaged ones were finally written off last month.

However, general public in Japan does not seem to be far from convinced. The disastrous accident in Fukushima including the triple melt throughs was the kind of incident they had been announced as once in tens of thousands years, virtually means "the never case."

Who would listen to the same mouthes warning "what if"s of the coming summer possibly without nuclear power? They should have warned the very one, that happened in March 2011.

Ray

Is man really a thinking reed?

I was looking for the topic of my speech at the local Toastmasters club when I came across the TED presentation "The real reason for brains" by Daniel Wolpert.

His argument that the brain is not an organ to think, but one for controlling complicated movements of body was gripping. It was also relevant for my assignment at that speech, effective use of body language.

I constructed my speech around the episode he introduced in the presentation, that the chess computer Deep Blue beat the human grandmaster, Mr Kasparov in 1997, but the computer would be no match for a five-year-old kid in physically moving chess pieces.

In the opening of my own speech, I challenged the audience if man is really a thinking reed. In the end of it, I concluded that man is more like a dancing straw as the brain is a controller of complicated movements. Fortunately, I managed to make it interesting enough and received good feedback.

I included the following question in my speech, "Is it actually easier said than done, if a brain is not to think but to control complicated actions?" I mean by "said", all the details required to reproduce the exact actions involved are explicitly expressed.

I found that it is rather easier done than said, as I am writing about what I had done in my speech ;-)

Ray

New Year's Resolution

A bit late to say happy new year, but this is my first post for 2012. So I would like to share my new year's resolution here.

Last year's one was "Make time work for me." It worked to some extent as I started many things which might work for me in the future. Some of them are now getting traction.

However, the catastrophic earthquake in Japan on 11th March and the following nuclear disaster remind me of the Buddhism doctrine that nothing in the world is under complete control of a human, the cause of every pain in human life.

So, I have chosen "Benefit from the unexpected" for this year's resolution. Contrary to what it may sound, it actually means "leave nothing to chance." To benefit from the unexpected, you need to be ready for them even though you don't know what they will exactly be. In other words, "Preparedness with Flexibility" is my policy for 2012.

Ray