Friday, September 12, 2008

Error Management

"[E]rrors are a result of both the human factor and the system in which we operate. To prevent and manage errors, one must address the human element alongside the system people interact with and the tools they use."

Craig Silverman, Regret the Error

This is a book about errors in journalism and the media -- slips and mistakes -- but has broad applicability to other walks of life. Silverman founded a useful and amusing website: RegretTheError.com. In a section titled, "A Theory of Error,"he draws upon the work of cognitive psycholgist James Reason to explore the nature of error,especially in so-called "high reliability" systems,and why errors keep happening.

"[I]t is often the best people who make the worst mistakes -- error is not the monopoly of the unfortunate few."

The notion of "brainlock" is comforting. We know what to do or what is correct and yet we do otherwise. The "swiss cheese" theory is more worrisome. Systems, any systems, are like layers of swiss cheese with all their myriad and seemingly random holes. When these holes somehow line up and there is a burst of sunlight, we've got big problems.System failure.

And then, of course, there's Freud's Psychopathology of Everyday Life.

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