errors

So, what do you do when your organization is...wrong?  Has made an error?  Blew it?
When there are problems with performance--say, an individual DID something or DIDN'T do something they should have--I often ask myself whether there was a COMPETENCY error, or a SYSTEM error.


In the medical field, it seems that about 90% of errors are system errors.  The competency errors are often simple gaps in knowledge, but sometimes they're more willful incompetence.  I'm pretty sure I'm dealing with willful incompetence when the person I'm talking to begins their explanation of the situation with, "I've been doing this for XX years...and I know how it's done!"


There is nothing...NOTHING, in the practice of medicine that has not changed in the last 20 years.  Some industries may not change much (say...classical violin).  Most other industries change.  


But still, most of my effort goes in to dealing with system errors.  If you're not more-or-less continuously redesigning your processes, then you're

• lucky to be in a business where the external environment doesn't change
• not paying attention