Quotation from: The Checklist Manifesto – how to get things right by Atul Gawande
We talk about our great saves but also about our great failures, and we all have them.
The question … to answer was why we fail at what we set out to do in the world.
We have just two reasons.
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works. Failure of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort.
The second is ineptitude – in these instances the knowledge exists, yet we fail to apply it correctly. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated… philosophers gave these failures so unmerciful a name – ineptitude. Those on the receiving end use other words, like negligence or even heartlessness.
Why do we make mistakes?
Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them.
Avoidable failures are common and persistent, not to mention demoralizing and frustrating. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably.
Knowledge has both saved us and burdened us.
Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually – the amount of harm remains substantial.
We continue to have upwards of 150,000 deaths following surgery every year – more than three times the number of road traffic fatalities. Research has consistently showed that at least half our deaths and major complications are avoidable.
The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made. They persist despite remarkable individual ability.