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Sunday, September 17, 2017

Blunder of the Week

Can mistakes be good? Mistakes add value if we learn from them. The HPO Center discusses having "blunder of the week" on the agenda. 

Starbucks uses the LATTE acronym in training and practice:

L - Listen to the customer.
A - Acknowledge the problem.
T - Thank the customer for bringing it to their attention.
T - Take care of the problem
E - Explain to your peers what happened and the solution

Bobby Knight opined, "basketball is a game of mistakes." That presents fertile opportunities for teaching and correction. 

Mistakes are inevitable. But our attitude is a choice. In The Vision of a Champion, 
Anson Dorrance writes that girls need positivity both in comments and film review. He thinks that negativity can shatter their confidence. Nassim Taleb, author of The Black Swan, reminds us that "exotic" problems are more predictable than we think. For example, who would have guessed that animal trainer Roy Horn would be attacked by a tiger? In Black Box Thinking, Matthew Syed explains why professionals go wrong in aviation, medicine, sports, and other disciplines. Ego is often the problem as experienced pros simply cannot believe that they are wrong. For example a surgeon refuses to change his gloves (the Anesthesiologist suspects latex allergy) until he is threatened with real-time report to the hospital administration (possible loss of practice privileges). 

Inattention contributes to many system failures. One out of eight verbally transmitted messages is heard incorrectly, making readback essential. 

Miscommunication occurred. How many times have we seen players unaware of or simply forget their defensive assignment? It validates court communication at all times. 

Sometimes players "freelance". They ignore their assignments because they misread the game situation, lack strategic understanding, or are just 'contrary' personalities. In Legacy, James Kerr explored the New Zealand "All Blacks" motto, "No dickheads." The Patriots share their overarching philosophy, "Do your job." 

Emotion clouds our judgment. In the throes of competition, stress hormones surge, and players literally develop "blind spots" or "tunnel vision". "Choking" is a physiology. Calm and clarity come with experience, practice, particularly in 'situational awareness'. 

Train to the level of your competence. Did the problem track the individual's ability and experience, or did training fail to meet their needs? One size does not fit all. 

The blunder. I worked in the ICU and examined an older woman. I told the nurse that the patient's hair had an unusual coarseness, sometimes seen with an underactive thyroid. She explained, "it's a wig."