Editor’s Notebook: On Being Wrong (and Human)
May / June 2011
Editor’s Notebook
On Being Wrong (and Human)
I’ve developed a soft spot for error—not for the stubbornness and denial that too often accompany error, nor of course for the harm that can result from it. I’ve been charmed recently by people who are comfortable admitting error and who accept that being wrong is part of being human. Learning to accept and even embrace the fact that mistakes are inevitable establishes humility as the foundation for improving performance and living contentedly with others and ourselves.
At the unSummit on Bedside Barcoding (www.unsummit.com), Jerry Fahrni, PharmD, gave a talk called “The Real Work Starts After Implementation.” Jerry is an effective speaker—informative, confident, and relaxed. In that style, he talked about many things that went wrong with the barcoding implementation at a large hospital for which he, as the IT Pharmacist, was responsible. He had prepared thoroughly to go live with barcoding for medication administration—assembled an interdisciplinary team, tested software and hardware, saw to myriad details that are well known elements for success—and, yet, all kinds of problems presented themselves as the hospital adjusted to working with the new system. Labels were misapplied over other labels, obscuring important information; drop-down menu items were chosen because they appeared at the top of a list, not because they were the correct choice; barcodes got scratched in handling, etc. Some glitches remained mysterious and eluded correction through weeks of investigation. Jerry conveyed the bafflement, surprise, satisfaction, duh! moments, and lessons to which we all can relate. The audience was engaged and sympathetic as Jerry’s stories rang true.
Kathryn Schulz is another charming error expert, whose name on Twitter is @wrongologist. Her TED talk, “On Being Wrong” is an excellent introduction to her work: http://www.ted.com/talks/kathryn_schulz_on_being_wrong.html. Schulz is the author of Being Wrong: Adventures in the Margin of Error and “The Wrong Stuff,” a series of interviews for Slate (www.slate.com/blogs/blogs/thewrongstuff/default.aspx). In her TED talk, Schulz explores the experience of being wrong, pointing out that disappointment, embarrassment, and shame are associated with the realization of being wrong, not with wrongness in itself. In fact, the real-time experience of being wrong feels exactly like being right, which of course is the problem. Schulz embraces being wrong as a vital part of the human condition, crucial to learning, and sometimes an opportunity to go in directions we might not otherwise have discovered.
Accepting the fact that we all make mistakes is an important step toward developing and accepting systems, such as bedside barcoding, that can protect patients from error and harm. When we go beyond acceptance and join with colleagues in appreciation of our occasional slips and lapses, error becomes an opportunity to connect around our shared fate.