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.
