Tuesday, May 22, 2012

An error occurred. Suspend all surgery in the US?


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.

More of my blogs about system error here, here, here, and here.

7 comments:

Tonja said...

Good lord. I hate the "we gotta look like we're doing something" atmosphere. It usually produces stupidity in policy, or crushing un-needed paperwork.

Skeptical Scalpel said...

Tonja, Thanks for commenting. I hate it too. That's why I keep talking about it.

Graybill said...

We just went hiking alone the Skyline Drive near our home. The grass along the parkway is already quite high. Visibility will be poor before long. Oh well at least they're "doing something."

Skeptical Scalpel said...

Just wait a few months. The report will be issued. Policies will be promulgated. The grass will be mowed in a different way.

RobertL39 said...

I do NOT disagree with your comments about blaming everything on 'system error'. You are right on the money. But remember that one of the reasons they "have to" do these in depth analyses is CYA. If they don't and another employee is injured mowing, the lawyers and their supposedly deserving clients will be coming out of the woodwork asking why they didn't DO SOMETHING ABOUT IT!!! "People were being injured and it didn't occur to you to stop mowing until you figured out why?" And of course when someone is bitten by a snake in the long grass that wasn't mowed, "Why didn't you DO SOMETHING ABOUT IT!!" It's a no-win situation for everybody. Thanks to all you personal injury lawyers out there! Gumming up the works for all of us.

Skeptical Scalpel said...

Robert, Thank you for commenting. I agree. I hope no one is bitten by a snake because what would be the solution to that system error?

RobertL39 said...

Why, mow the grass, of course! What goes around comes around. It's all just a big circle.

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