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amelia_lim's review against another edition
4.0
Unlike what the book title stated, while stories like The Null problem, the fact that Matt was annoyed by the incorrect geometry of the football street signs to the extent that he started a petition, bug fixing with a bureaucracy patch, and (I love this one) a programming error of a game makes Gandhi the most nuke-happy leader are really hilarious, most errors ended up as tragedy.
I like that Matt explained the idea of the Swiss Cheese model or Hot Cheese model (new version of Swiss Cheese), it's a view of accident management.
It acknowledges that people will inevitably make mistakes a certain percentage of the time. The pragmatic approach is to acknowledge this and build a system robust enough to filter mistakes out before they become disasters. When a disaster occurs, it is a system-wide failure and it may not be fair to find a single human to take the blame.
A patient died from drug overdose. Instinctively, the nurse who set up the pump which infuse drug into the patient is put to blamed. The CHI+MED (Computer-Human Interaction for Medical Devices) did a good job at handling this case.
It's not a good system simply to remove everyone who admits to making a mistake, thus leaving behind a team who 'do not make errors' and have no experience of error management.
First of all, there's a lot that can be learned from in terms of how drug-dose orders are describe, how medical instrument (like the pump) can have built-in checks to know what drug is being administered and do a finial check on the rate. A calculator app has also been developed since then and blocked over 30 common medical calculation errors.
I was raised in this kind of school environment where in general, students get punished without further investigating when they make mistakes. For example we got caned for calculating 1 + 5 wrongly. So my brain has formed this "HUMAN CANNOT MAKE MISTAKE" mindset. The Swiss Cheese way of viewing mistakes certainly had an impact on me. Rather asking "Who?" and blaming a person next time when something goes wrong, I will take a look at the whole system and analyse every aspect that could cause things go wrong, then try to solve them.
I like that Matt explained the idea of the Swiss Cheese model or Hot Cheese model (new version of Swiss Cheese), it's a view of accident management.
It acknowledges that people will inevitably make mistakes a certain percentage of the time. The pragmatic approach is to acknowledge this and build a system robust enough to filter mistakes out before they become disasters. When a disaster occurs, it is a system-wide failure and it may not be fair to find a single human to take the blame.
A patient died from drug overdose. Instinctively, the nurse who set up the pump which infuse drug into the patient is put to blamed. The CHI+MED (Computer-Human Interaction for Medical Devices) did a good job at handling this case.
It's not a good system simply to remove everyone who admits to making a mistake, thus leaving behind a team who 'do not make errors' and have no experience of error management.
First of all, there's a lot that can be learned from in terms of how drug-dose orders are describe, how medical instrument (like the pump) can have built-in checks to know what drug is being administered and do a finial check on the rate. A calculator app has also been developed since then and blocked over 30 common medical calculation errors.
I was raised in this kind of school environment where in general, students get punished without further investigating when they make mistakes. For example we got caned for calculating 1 + 5 wrongly. So my brain has formed this "HUMAN CANNOT MAKE MISTAKE" mindset. The Swiss Cheese way of viewing mistakes certainly had an impact on me. Rather asking "Who?" and blaming a person next time when something goes wrong, I will take a look at the whole system and analyse every aspect that could cause things go wrong, then try to solve them.
10_4tina's review against another edition
funny
informative
lighthearted
fast-paced
4.25
Mathy. Funny. Fascinating.
I love these kind of anecdotes that are interesting and funny and teach you something all at once. I learned a lot, totally changed my views on excel, and fell in love with math all over again.
Here are some of the interesting tidbits:
chapter 0:
-middle in respect to multiplication vs addition (middle of 1-10 is 3 due to logarithmic mental jumps in respect to multiplication)
chapter 1:
-October 4, 1582 was directly followed by the 15th of October in catholic countries based on a decree from the pope
chapter 3:
-the test for identifying a number - imagine asking someone for half of it - (height is a number - phone number is not a number - if the response is not to divide it, but rather to split it, it's not a number)
chapter 4:
-football (soccer) socks - simultaneously right and wrong
-3 cogs stuck together
chapter 6:
-a bug fixed with a bureaucracy patch - 256 axels on trains are not aloud due to a coding problem - rewriting the manual was easier than fixing a bug in coding
chapter 11:
-a mathematical certainty: you can find any pattern you want as long as you are prepared to ignore enough data that does not match
I love these kind of anecdotes that are interesting and funny and teach you something all at once. I learned a lot, totally changed my views on excel, and fell in love with math all over again.
Here are some of the interesting tidbits:
chapter 0:
-middle in respect to multiplication vs addition (middle of 1-10 is 3 due to logarithmic mental jumps in respect to multiplication)
chapter 1:
-October 4, 1582 was directly followed by the 15th of October in catholic countries based on a decree from the pope
chapter 3:
-the test for identifying a number - imagine asking someone for half of it - (height is a number - phone number is not a number - if the response is not to divide it, but rather to split it, it's not a number)
chapter 4:
-football (soccer) socks - simultaneously right and wrong
-3 cogs stuck together
chapter 6:
-a bug fixed with a bureaucracy patch - 256 axels on trains are not aloud due to a coding problem - rewriting the manual was easier than fixing a bug in coding
chapter 11:
-a mathematical certainty: you can find any pattern you want as long as you are prepared to ignore enough data that does not match
gregodenwald's review against another edition
funny
informative
lighthearted
reflective
medium-paced
4.5