JUST PLANE CULTURE
around those new to the industry (not a surprise) and those who were very experienced (not expected).Although the climb in errors is not as steep as the newbie’s, it is still an alarming phenomenon.
ERRORS
wants and meet their expectation. The customer is always right. The customer is not right in this case. The customer has been acclimated over time to expect that kind of response and the trend continues. The doctors, in like kind, respond to that “norm” and jam as much as possible in their brains. Even an actor who has memorized his lines to the play will not recite them verbatim every time. It has been statistically shown that such diagnosis from memory produces only 60 percent accuracy. They do the same things that we are accused of as aircraft technicians — make educated assumptions and shot-gun a problem. Our errors as aircraft technicians result in less than two
TENURE
PUTTING IT TOGETHER Putting the two error curves together forms a total picture of error analysis. I guess the trick is to not learn too much and get out of
the business at mid-career and find another profession since it is just going to get worse, right? No, wrong answer. This is not entirely an individual fault problem. As professionals our knowledge and training, and the expected recall of that information, are put to the test on a daily basis. We are also expected to know certain information without looking at a reference even though a reference is required when it comes to applying that knowledge. Imagine seeing a doctor who said, “I’ll have to look that
up.” Would your level of confidence be less? You expect your doctor to have an answer without using a reference. They memorized a bunch of books and should be able to recite them when required. You have placed that expectation upon them and they, in turn, respond as you expect. This is customer satisfaction theory. Find out what the customer
percent of aircraft fatalities. Not bad, when you consider the number of people flying. The rate is about the same with medical errors in American hospitals. The importance is driven home when you put numbers to that statistic. There are 100,000 deaths due to errors per year in American hospitals. There is enough information to show that if a reference or checklist would have been used, the deaths could have been reduced drastically.
TYPES OF ERRORS In the book “The Checklist Manifesto,” author Atul Ga- wande points out how routine surgical tasks are so com- plicated that errors are inevitable. He divided error into two categories. The first is errors of ignorance (mistakes we make because we don’t know enough). This is your learning curve where errors are less over time. The second is errors of ineptitude (mistakes we made because we don’t make proper use of what we know). This is the arrogance or over- confidence factor where errors increase over time. He goes on to state that in the modern world we are more apt to error due to ineptitude. We are used to checklists in aviation. Pilots and maintenance staff use them. When it was suggested that checklists be used in the medical profession, it was met with stiff resistance even though it was shown that it would save lives. The medical doctors thought it was unprofessional to
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