We have just two reasons that we may fail.
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.
For nearly all of history, people’s lives have been governed primarily by ignorance.
It looks like there was some ineptitude in Dallas with the now known Ebola patient. Apparently, one nurse learned that this man had traveled to Dallas from the highly-infected area in Africa. But, that message was not clearly heard, or clearly communicated… ineptitude.
In the book The Checklist Manifesto, Mr. Gawande describes how checklists not only have to provide checks on what is done, but on who communicates what to whom, and when.
Ineptitude! is what you get when checklists are not in place, or if in place, not fully followed.
We’ve got to get better at designing our systems. And then we’ve got to get better at implementing these systems. The Dallas Ebola story sounds like a classic systems failure. Somebody – maybe many somebodies – messed up.
Another quote from the book:
Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. (emphasis added).
If I miss a comma in a blog post, it’s not a big deal. If a Secret Service agent misses a warning; if a nurse does not communicate that a person recently traveled from a high-infection region – that could be a very big deal.