Here is an extreme “system error” type of response to an event which seems to have been a human error.
According to CBS News: “Mowing at all national parks has been suspended indefinitely because of safety concerns after a maintenance worker cutting grass along the Blue Ridge Parkway in North Carolina fell to his death.”
The unfortunate victim was killed when the mower he was riding on fell down a 140 foot embankment. The report says, “He was trimming a 12- to 15-feet-wide area between a wooden guardrail and a cliff when he lost control of the zero-turn riding lawnmower and went over the edge.”
The National Park Service investigation of the accident is already complete but the findings will not be released for months. It is not clear why it will take so long. [That’s a subject for another post.]
If you have been following my blog, you know that I have consistently questioned the tendency of organizations, including hospitals, to blame adverse events that seem to have been human errors on “system errors.” Once a problem is deemed a system error, policy changes must be made. New protocols are written. It gives the appearance that the organization is “doing something” about the perceived system error. In my experience, most of the time the changes are soon forgotten and everyone moves on.
Pending the results of the investigation, I could possibly understand suspending the use of all riding mowers of the type used by the victim or suspending the mowing of grass along the edges of cliffs, but to suspend all mowing of grass at all 397 national parks seems a bit excessive.
I had tweeted a brief mention of the CBS News story and one of my followers, @dockj, responded, “What if we stopped all surgery for the entire country every time there was an error?”
What a great question. I tweeted back that I wished I had thought of that. I hope the patient safety gurus don’t hear about this or it might be the next step.
Meanwhile, watch out for snakes in the tall grass when you visit a national park.