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A review by amelia_lim
Humble Pi: A Comedy of Maths Errors by Matt Parker
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.