Friday, March 27, 2009

Why We Make Mistakes

For years I've been fascinated with the concept of human decision making. I've enjoyed reading books that explore this concept. I'm also intrigued about the strategies that people use to justify their mistakes and the cognitive dissonance required to make your actual decisions jive with what you know is right.
Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average by Joseph Hallinan is my latest read on this subject. In the opening chapter of the book Hallinan describes a commercial airliner simply flying into the ground because they got too hung up on a small light that was burned out ans ignored the fact that the plane was slowly loosing altitude. I felt that this one simple metaphor described the rest of the book. We do lose focus of the things that are truly important. And all too frequently our focus was shifted by relatively trivial details.
Hallinan skillfully points out how uncommon common sense really is. But rather than just blame the decision maker he talks about how we can put ourselves into positions that will help to make better decisions. sometimes it takes a design difference so that, for instance, clockwise is off on all the knobs. Things like always putting the hot on the left and the cold on the right, etc. Sure it sounds like a simple design issue but he gave some frightening mortality statistic from an anesthesia machine that was clockwise for off on on drug and counter-clockwise for another.
Hallinan compared the airline industry to operating room. In the past few decades accident rates in the airline industry have dramatically dropped and there has been an increase in the operating rooms. Hallinan points to the main cause of this as the changes that have been made to the authority system in on and not in the other.
In the airline industry anybody the cockpit is virtually free of authority struggles. Many decisions are not based on rank or position. A 20 year old air traffic controller tells the pilot where to land and the pilot obeys and doesn't pretend that he knows better just because she's been doing flying since the controller was a kid. In the cockpit as well the co-pilot and even attendants are valuable resources and their input is encouraged.
Conversely, this authority system seems to be trending the other direction in the operating room. Doctors all too frequently are seen as unquestionable. Even in situations where nurses have spoken up to prevent the error Hallinan sights instances of flipped x-rays and the wrong limb being removed.
A few years ago my youngest daughter had to have a tooth pulled. We went to see the specialist with the x-ray from our dentist. She'd taken a fall on the driveway and one of her teeth was a starting to go gray. The x-ray seemed to confirm that the root on the graying tooth was dying. When we went to get her tooth pulled the nurse questioned the x-rays. She thought we we looking at it backwards. The dentist did not question her and called to have another x-ray taken just to be sure. She was absolutely right. In spite of the fact that one tooth was starting to turn gray it was the tooth on the other side that had the dead root. The dentist went ahead and pulled the dying tooth and the gray tooth eventually regained its color. Had that nurse not spoken up and, more importantly, had the dentist not accepted her advice Eve would have had to go back and have the correct tooth pulled later and they'd have had a very upset father on their hands. I'm very grateful to have had a dentist who was willing to admit that he could make mistakes and ultimate prevent them.
I enjoyed this book and would recommend it to anybody who is aware that they can make mistakes. I also think it should be force feed to anybody who thinks that they can't.


  1. Another book for me to put on my reading list. I was really pleased with the nurses and dentist, too. Eve is a very trusting little girl and it would break my heart to have taken her for care and done harm instead. Thanks for posting this review!

  2. I shall have to put this one on my reading list as well. Since EVERYONE makes mistakes, this is a book that should be read by all.