Archives for posts with tag: errors

There are few people who would argue with the statement that math is at the heart for most of our modern world. What is less well understood is what happens when that math goes wrong. And it does. All the time!

Mr. Parker’s highly amusing and thought-provoking book is about math and computers, but what becomes clearer as the book goes on is that this is also a book about systems and how and why systems can fail. There are lots of examples of people adding up numbers incorrectly or trying to take shortcuts to make the math simpler, which in turn leads to devastating and sometimes lethal consequences. However, it the subtler applications of mathematics where “Humble Pi” really scores.

For example, looking at 30- or 40-year-old kitchen appliance, still in use, is often accompanied by a phrase such as “they don’t make things today like they used to.” While this might seem obvious at first glance given that we are talking about an appliance working well beyond its expected lifespan, this is actually an example of “Survivor Bias.” If we looked at how many of the appliances had been manufactured, and then looked at how many were still in daily use, the chances are that we would recognize that this surviving appliance is an outlier and that the vast majority of the appliances have actually long been replaced or broken down. It is only the existence of this surviving outlier that prompts the idea even though we would likely not comment on its existence were more of the appliances in existence. The appliance’s rarity generates a false narrative that can only be understood by understanding the underlying math of the number of appliances produced.

For managers there is much to take away from Humble Pi. Mr. Parker encourages us to look at systems like layers of sliced Swiss cheese. All systems should be made of multiple layers – the checks and balances of any good system. But it is important to understand that there are possibilities for mistakes in every layer of a system – the holes in the cheese. The challenge as designers of systems is to ensure that the holes in each layer do not align. The author uses the example of two different nurses in a hospital performing a complicated drug calculation the same way and both making the same math mistake leading to a medical error.

Related to this idea of errors being a natural part of a system is the impact of a lack of tolerance for errors on new employee training. If managers terminate employees for making mistakes, the people who are left to train new employees are those who are must less likely to make mistakes. These are probably the worst people to train new employees who are obviously more prone to making mistakes. If instead, we teach employees to work a system that can detect mistakes and provide feedback, a system where the holes do not line up, then we will overall have far less mistakes – even when people are new. As the books says, humans can be very resourceful in finding ways to make mistakes.

This is not just a book about rounding errors, and why you should turn your computer off regularly. It is a book about what it means to be human in a world that relies and is built on mathematics, which humans are inherently not very good at. It is a fun and interesting read that will stay with you long after you put it down.

A brilliant book on change and how to apply it in the real world. Over 250 real world examples and ideas underline the authors basic concept – getting people to change is like someone riding an elephant. Appealing to the logic of change is like appealing to the rider of the elephant. The elephant itself is the emotional connection to change. Finally, the path is the environment which can either help or hinder change.

Through numerous examples, the authors show that by appealing to the rider of a situation (the logical argument), the elephant (emotion), or the path (the environment) change can be effected by addressing these disparate elements individually, or together.

An excellent example of this is provided with nurses making errors in the dispensing of medications to patients. The hospital used in the example had an error rate of 1 in 1,000 – pretty good, but still a lot of errors. The nurses understood the need to not have errors, so the rider / logical part of the problem was not at issue. Likewise, nurses directly saw the effect of errors in medication had on their patients and so had a direct emotional connection – the elephant was on board too. The issue was in the environment or path. Nurses are constantly interrupted by doctors, and other nurses, while they are working and found it difficult not to help when asked, thereby distracting them from their main task. The solution? Tweak the environment / change the path so that nurses did not get distracted.

A bright orange vest was employed whenever a nurse was dispensing medications so that everyone else on the floor knew that they were not to be disturbed. The program was universally hated – the rider element thought it was unnecessary, the vests got lost all the time and hated that they could not help their doctors and colleagues. The elephant part of the problem felt that they might as well wear a dunce cap – the nurses felt demeaned and that the vest drew attention to the fact that they made mistakes.

This might have spelt doom for the program until the data came back. Over six months every department that employed the program saw a decrease in errors of 47%. Needless to say the change in the path / environment won over the rider / logical objections and the elephant / emotional objections because it worked.

The book is also a great champion of checklists which have gotten bad name precisely because they work so well. They can be seen as dehumanizing and giving rise to the idea the checklists mean “a monkey could do it.” Like most objections the book deals with this argument deftly. “Well, if that is true, grab a pilot’s checklist and try your luck with a 747.”

There are a number of other elements that I can’t do justice too here: black and white goals, precise clear instructions, the power of action triggers, and the how to harness the herd to improve culture. But these elements are really tweaks to the fundamental concept of the logical, emotional and environmental components of enacting change.

At the back of the book is, essentially, a manual for enacting change complete with a web link to resources and PDF of a one page overview that the authors encourage you share! It is here by the way. This alone is worth the purchase price of the book and will ensure that the book stays on my desk rather than on a bookshelf.

Wonderfully researched, well thought out, and very smart. “Switch” is essential reading for anyone who want to understand why change can be difficult and what it takes to implement change against the odds. It should also be a template for other business books – ditch the theory unless you can prove it I the real world and show how it applies to the real world. Authors please take note.

Can’t recommend this book enough and owe a huge favor to the person who bought it for me.

(Clicking on the cover above will take you to the book’s Amazon page and contribute to my book buying habit / problem.)

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