Editor’s Notebook: Swiss Cheese Model Applies to Publishing, Too


November / December 2005

Editor’s Notebook

Swiss Cheese Model Applies to Publishing, Too

Unfortunately, what I have learned about designing systems for safety didn’t protect this magazine from some nasty errors in the last issue. Mike Dempsey’s article about active-RFID, “Intelligent Location” (pages 38 — 41 in the September/October issue), was marred by extraneous letters, words, phrases, even a whole sentence that had been deleted in the final manuscript but showed up in the printed version. That led to consternation, embarrassment, apologies, investigation, and redesign of processes. Sound familiar?

With over 25 years of experience in publishing, I’ve seen my share of production snafus, but I had a different understanding of what went wrong this time based on what I’ve learned about patient safety. Just as James Reason described in his Swiss Cheese Model, multiple errors, each of which should have been caught and corrected but wasn’t, aligned for successful passage through our production process, right onto the printed page. How did we miss them? Unexpected personnel changes in the department came at a bad time; we rushed the process when we fell behind schedule; I grew weary and sloppy as time and problems dragged on; and the Track Changes feature in Microsoft Word is helpful but tricky to manage even under ideal circumstances. Those conditions aren’t excuses; rather, I see them through my safety lens as vulnerabilities in our system. My colleagues in production at Lionheart Publishing and I have discussed what went wrong and are working now with heightened awareness and a new process for handling manuscripts that will help us anticipate and divert errors.

I compounded this mess with flawed judgment around communication, yet another favorite safety topic. Maureen Deiana, who works with Mike Dempsey at Radianse, let me know immediately when she found the first of multiple errors in the printed article. Later that morning, I discovered more. I should have called Maureen immediately with what I had found, but, trying to save face, I delayed that call as I worked with our reprint manager to provide clean copies of the article in recompense. Meanwhile, mundane stuff — phone calls, email — distracted me further. Later that day, Maureen called me with increased disappointment in her voice to say that she had found more problems in the article. I was mortified that I hadn’t done what I knew was the right thing — to have called her immediately. I knew better but let embarrassment and wishful thinking influence my actions. I hope that Maureen, Mike, and all PSQHreaders who struggled to read the article will accept my apologies. A corrected version is posted on our Web site along with all of the articles from September/October and all previous issues.

In this issue, our series from the Quality Colloquium continues with three articles from this year’s conference, held in late August in Cambridge, Massachusetts. The series will continue through the year, with many important summaries written by experts who presented at the Colloquium. Look for those articles labeled “Proceedings From the Quality Colloquium.”