I have changed the title and site URL of this blog again. I hope it does not trouble anyone too much as I had left this without any updates for quite some time.
The initial title I started this blog with was "More a Kiwi than a Kiji" meaning that I am becoming a Kiwi, the New Zealand national bird, than a Kiji, the Japanese counterpart and representing my sentiment as an expatriate.
The second and previous title was "Ray's Adverse Events Report in the Kiwi Life of a Zen Health IT Analyst", a very lengthy one as the result of trying to pack as much as information on who I am and what I do but I now think it very verbose.
So, I made the new one shortly "Trilogues within me" which I hope to stay for a longer time than previous two.
The new title reflects the increased significance of other two languages than Japanese in my thoughts, especially of English. Honestly, nowadays I am more relaxed in talking and corresponding in English than in Japanese even though the latter is my mother tongue.
It does not necessarily mean that things go more smoothly in English for me. Quite opposite is often the case. Actually more often things would go wrong in many reasons including different cultural expectations. However, I know misunderstandings cause more damages on the both sides in communications in Japanese, because those are less tolerant to the unexpected, namely mistakes.
Now I am so away from the ordinal everyday life in Japan or in Japanese culture, I am afraid my values are so apart from those of people living Japanese way of life.
A while ago, there were disputes in Japanese social media about a famous disabled author refused to dine in an artisan Italian restaurant because of the reservation without declaring need for assistance with wheel-chair access. Eventually the restaurant owner apologised with an excuse that he and his staff just couldn't handle the situation without prior arrangements and didn't mean any discriminations.
I think it is a good example that communications in Japanese suddenly became difficult when something unexpected happens. So Japanese are generally have been taught to behave according to others' expectations. I wish that tolerance to the unexpected becomes norm as the ever increasing global exchanges require it even for people in Japan.
Ray Murakami
Saturday, 29 June 2013
Friday, 23 November 2012
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:
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:
Wednesday, 19 September 2012
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
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
Tuesday, 4 September 2012
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
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
Friday, 31 August 2012
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
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
Wednesday, 29 August 2012
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
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
Tuesday, 28 August 2012
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
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
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