Why We Make Mistakes by Joseph Hallinan

The continued wanderings of a newly minted librarian

Hallinan, J. T. (2009). Why we make mistakes. New York: Broadway Books.

Hallinan’s Why We Make Mistakes is a frightening and yet entertaining book. Some of the examples and statistics of medical mistakes and the statistics of weapons that get past bagage screeners are truly scarey.  Hallinan looks at radiologists and baggage screeners both jobs which require one to scan for things (guns, bombs, cancer) which most of the time will not be found. The way we work, it is harder for us to find something when it doesn’t show up often.

“… [in one study] doctors at the Mayo Clinic went back and checked the previous ‘normal’ chest X-rays of patients who subsequently developed lung cancer. What they found was horrifying; up to 90 percent of the tumors were visible in the previous X-rays. Not only that, the researchers noted, the cancers were visible ‘for months or even years.’ The radiologists had simply missed them.” (Hallinan, 2009, p.24).

Apparently the government wont release the miss rate of bagage screeners but:

“…a test in 2002 indicated that they missed about one in four guns. During a similar test two years later at Newark’s airport, the failure rate was nearly identical: 25 percent. More recently, 60 percent of bomb materials and explosives hidden in carry-on items by undercover agents from TSA were missed in 2006 by screeners at Chicago’s O’hare International Airport. At Los Angeles International Airport, the results were even worse: screeners mised 75 percnet of bomb materials” (Hallinan, 2009, p. 24).

Hallinan points out how bad multitasking is. Doing anything while driving (besides watching the road and driving) raises the chances of being in a collision. Yet modern cars are equipped with so many bells and whistles that require the driver to take their eyes off the road in order to opperate them. Multi tasking at work does not save time. We can’t really do two things at once, when we multi task we generally go from one thing to another and then back. The break in concentration is more disruptive… once you have been interupted in a task it takes 15 minutes or so to get back into the groove of concentration for optimum performance. It would be less time consuming to complete one task and then move on to the next, but of course the buzz word around offices and corporations is multi tasking.

Basically, we make mistakes because we are over-confident and we are biased. Unless we compensate for those things, they will cause mistakes. One neat comparison made by Hallinan was between an operating room in a hospital and a cockpit of an airplane. Both spaces have teams of people working for one cause (either a successful operation or a successful flight and landing). However, mistakes made by pilots have been drastically cut because the FAA has made regulations which eliminate some of the sever hierarchy. The pilot is no longer the supreme comander who controls everything. Every person in the cockpit is supposed to speak up whenever they see something that isn’t right. This is confirmed by pilots themselves—they expect the others to speak up and welcome it. This saves lives. In the operating room the head surgon is usually the supreme commander and can overide what anyone else says. Many surgical staff say they would not speak up because they would not be listened to. Mistakes have been recorded when a training surgon trys to do something and is “corrected” by the supervising surgon. When the trainee speaks up and says they think they are right and the “correction” is wrong, they are shot down. People die.

In order to reduce some of the mistakes that are made, we need to look at why the mistake is made. Rather than looking “down” to who was the last person to interact with the patient or the last person to inspect an airplane, we need to look “up” the chain and see what rules or other circumstances were involved. Hallinan gives the example of mass overdoses of medicine given in a hospital. The overdoses were given multiple times and by different nurses. The problem wasn’t really the nurses, the problem was the two strenghths of this medication looked almost identical and were easily (and often) mixed up. The solution is to make the differences obvious (different colored lables, different shaped dispenser, etc).

This is a fascinating book on how our minds work and what we can do to help reduce our mistakes.

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