People make mistakes. It happens.

I still think its odd how we consistently seem surprised about this. We aren’t perfect. Things will happen. The real question is why did they happen.

Our first instinct is usually to blame the person. In my experience however, mistakes almost always reveal a breakdown in the system. Its one thing for Joe to make a mistake because he didn’t follow the SOP. Its quite a different thing if Joe made a mistake and there wasn’t an SOP or the SOP led him down the wrong path.

A few years back when I was working as a supervisor in a small hospital lab we had an incident in the blood bank. Now you may have heard about blood banks before but possibly not in the context of a hospital. If you donate blood you know that you go to the little blood mobile and donate your blood. After that, your blood goes to a blood bank where it gets tested for diseases and processed into units that can be transfused into patients.

In the context of a hospital, blood is purchased from the core blood bank and is stored in refrigerators at the hospital. They then do additional testing on the blood to see if its is compatible with your specific blood before giving you a unit.

So lets say I am a patient and I come in needing a unit of blood. The lab will send someone to draw my blood and will use the drawn blood to run tests to make sure I can receive that unit of blood without any reactions.

You probably have heard about blood type but there are many other factors that can cause you to have a reaction to blood you’ve been given. Antigens like Kell or E or duffy can cause reactions that can cause the blood you are receiving to make you very sick. There is a whole science behind making sure you get the right blood and its very important to get the right blood.

As you can imagine, there are lots of ways to mess this up. You can test the wrong patient’s blood when doing your initial tests. You can do the testing itself wrong. You can mix up the blood you are testing. Your nurse can mix up the blood they are giving. There are so many points along the line that the wrong thing can happen and the consequences of a mistake can be deadly.

Jumping back to our incident, it doesn’t really matter what exactly happened but something happened and it was severe enough that it caused an investigation. (Nobody was hurt thankfully). It’s easy in a time like this to start blaming the individuals involved. Why didn’t they follow this procedure? How could they mess this up? What we discovered however was that the system broke down.

We identified a couple issues.

1. Doctors and nurses were allowed free access into the blood bank and they would vehemently pressure the tech to give them the blood. Imagine trying to do something very technical with someone screaming at you to just hurry up!
2. The procedures were accurate but not easy to grab and quickly figure out what to do first.
3. Nursing started throwing out some of their checks in order to get the task done faster.

We made some changes to the system that improved it for everyone. We made our procedures easier to read under pressure. We tasked other techs who aren’t the blood bank tech with heading off angry doctors and nurses to give the blood bank tech the headspace they need to complete their tasks. And we started running practice runs for the specific issue that we faced that night.

How can this be related to development? Well first, it’s easy to just start placing blame on individuals when something goes wrong rather than looking at the system. Believe me, I’ve worked with enough people to know that its possible that certain individuals are just incompetent. I would say the vast majority of mistakes are made by people that are highly competent however and just encountered a unique set of circumstances. Instead of blaming individuals, look at the system. Is there a way you can improve your SOPs? Have you ever practiced bringing up the backup system? Do you have a review process that prevents big mistakes from making it to production?

Blaming individuals might make you feel better but if the issue was actually a system issue, the mistake is a ticking time bomb. It will happen again, it’s just a matter of when.