Trial By Error

I read this book because working in a pharmacy, I hoped that having an understanding of the psychological basis of error might be helpful in avoiding it.

The book starts with some history. In the early twentieth century Freud was pondering on apparent slips and “accidents” having a basis in the subconscious. I suppose according to Freud, if someone made a slip in dispensing medication it would be because they had some deep seated dislike of a patient, or harboured unconscious opinions about their treatment! Thankfully, other views from the early twentieth century have aged better. In 1905 Ernst Mach wrote that “knowledge and error flow from the same mental sources, only success can tell one from the other.” Mach is referring to the fact that certain helpful types of behaviour, can also cause problems. For example, people have the ability to learn skills which involve a high level of automatic facility, allowing musicians to play musical instruments, typists to type, drivers to drive cars – all without thinking about the mechanics of every string plucked, key pressed or gear changed. But this automatic facility, so useful in many situations, can be a liability when circumstances alter. Step from a manual car into an automatic and you can run into problems when your left foot wants to press a clutch that isn’t there. In a pharmacy, if you have dispensed hundreds of boxes of a medication in a particular strength, there is an opening for error when you come to dispense an unusual strength of that same medication.

I suppose an awareness of this kind of situation does potentially help guard against times when routine brings the possibility of diminished conscious control. But Human Error is not the book to go to if you want simple answers. First there are those bad outcomes arising from useful behaviour. Then there’s the sense that an error is rarely confined to one person. When things go wrong it is usually the result of lots of people making many decisions meeting varied circumstances, which finally lead down to the unfortunate individual who makes a blunder – the last piece in a malign jigsaw puzzle. Then there are the traps in all the means we employ to guard against error – automated systems leading to loss of skills in dealing with problems; or systems protected by layers of defence tending to soak up hidden deficiencies until there is a sudden failure. Oddly, I came away from this book with a greater acceptance of error, even in trying to find a way to avoid it. Error is inevitable, and if you make error a forbidden sin, then you can never discuss or learn from things going wrong.

It is perhaps ironic that Human Error is a highly academic book, which leaves nothing to chance in its numbered sections, sub sections and sub sub sections. It does not flow. Concepts have to be nailed down into endless acronyms, leaving me floundering amongst SLIMs, SLIs, THERPs, PSFs, PIFs and SUs. Even the name Three Mile Island gets turned into TMI. I did not enjoy wading through this academic acronym code. I can’t see any problem with calling Three Mile Island by that name as many times as required.

Nevertheless, if you can live with the style, and accept that you won’t find an easy prescription that will make you a more accurate, less error prone person, this is a very interesting book. I would recommend it to anyone working in a job where a small slip can have serious consequences; or to anyone making big decisions, where small, unintended consequences in those decisions can store up serious problems for the future.

A Poem Built With What3words

 

The view from humid.wiser.audit

 

What3words is a location app, dividing the Earth’s surface into 3m x 3m squares each with a unique three word name. Out on my bike at the weekend I started collecting word locations I might use in a poem. Here is the result, using some of the locations I rode through, combined with other locations around the world.

What3words

I stopped at a cafe where I found

Capers.anchovies.nuance

Collecting words.together.sounds

In a mood of sleepy.stop.salience

Like a cars.varying.guru

Using slick.laptop.glue

And stick.trumpet.type

I send my latest.scrap.invite

To arrive.train.alight

In my opinions.nest.igloo

The way there is over grass.parade.hint

Happy.stomp.hills

And walks.factories.print

In a field.readjust.fiction

Around the golfer.tree.diction

And via a wowed.blank.tone

And a balloon.patio.phone

I will give you a call and bring you gearbox.dispenser.home

Woodstock For Someone Who Wasn’t There

Woodstock 1969
Me, Mote Park 1969

It’s the fiftieth anniversary of Woodstock, three days of love and music.

In 2019, it is perhaps good to take a moment to remember Woodstock. This is not, I have to admit, because Woodstock and its time are a shining beacon, a state of grace from which we have fallen. The six year old me might have been running around in Maidstone’s Mote Park in August 1969. This was a point in my mother’s life that she recalled as “always sunny.” It wasn’t of course. In my own little world there were, no doubt, chilly days. And as for the world at large, take your pick of wars in Asia, or music festivals which failed to go nearly as well as Woodstock. Woodstock itself did not really indicate a new social promise. Keeping half a million people together in a field in increasingly unsanitary conditions could not have gone on longer than three days. Inevitably, all those people would then have to go back to their normal lives, to avoid dysentery if nothing else.

So Woodstock did not provide an escape from the world. It is more an idea of freedom than its reality. Fittingly, someone who wasn’t even at the festival wrote the definitive song about it. Joni Mitchell was in New York City in August 1969, fulfilling a prior engagement. Her song Woodstock came out of a dreamy longing that came from not being there.

In Woodstock, the singer meets someone on the road heading to Yasgur’s Farm. This festival goer comes out with some dreamy lines about about how people are made of stardust, and describes a desire to get back to the land and set their soul free. This sells it to our singer narrator. In asking to tag along we get these ambivalent lines:

Then can I walk beside you

I have come here to lose the smog

And I feel to be a cog

In something turning

So has she gone to Woodstock to feel like a cog in something turning, suggesting a positive sense of being part of something bigger than herself? Or has she gone to Woodstock to escape feeling like a cog turning in her mundane life in the city? It’s not clear.

Maybe she’s a cog no matter where she is, both in that negative city sense, and in the positive feeling of being part of something bigger than herself. Joni Mitchell didn’t actually get to Yasgur’s Farm, but the song suggests that you can feel like a turning cog anywhere – in a field in front of Jimi Hendrix, in New York, in Mote Park. The song suggests that if you look at it right, the world can be one never ending Woodstock Festival, where the sanitation needn’t be an imminent threat to public health.

Edith Wharton – Authors Are People Too

Scribner’s Magazine where The House of Mirth was published as a serial in 1905

Edith Wharton’s The House of Mirth describes the life of Lily Bart, an early twentieth century It Girl, who at twenty nine years old, has lived through eleven years on New York’s society party circuit.

Lily looks to the future and sees her life narrowing. Early in the book she is on the verge of marrying a fabulously rich man, only to turn away at the last moment because she doesn’t love this boring mummy’s boy. She also had the chance to marry a middling prosperous lawyer, who she does love, only to turn her back on that idea as well. After making these decisions, a general tendency to contrariness hardens into a firm determination to escape her fate. When problems created by others damage her prospects, Lily throws a few spanners of her own in the works. She is seemingly incapable of allowing herself to follow her natural course, whether this course is marriage to a rich man, marriage to a man she loves, the well paid life of a social fixer, or even a career as the owner of an elegant hat boutique. Whenever a course opens up, Lily helps shut it down. She wants to escape the social machine of which she is a part, only to find herself in a different part of the same machine. There are those who wear fancy hats, and there are those who make fancy hats for those that wear them. Both are part of the same mechanism.

So, on the positive side, this is a story which feels universal in the way it considers freedom and fate. On a less positive note, the book was a frustrating read, as Lily trips herself up over and over again. Then there is the voice telling her story, which for all its apparent freedom to look down on flawed human characters, has a few flaws and prejudices of its own. This waspish author voice is prone to switching between character points of view with confusing suddenness. I also found myself feeling distinctly uneasy towards the beginning of the book, reading the stereotyped portrayal of Jewish businessman, Simon Rosedale:

“a plump rosy man of the blond Jewish type, with smart London clothes fitting him like upholstery, and small sidelong eyes which gave him the air of appraising people as if they were bric a brac.”

I wondered if this was supposed to be Lily’s point of view, but as I say, point of view is not stable in this book, and remains ultimately with the author. This voice portrays many of her characters in an unflattering light, but does not otherwise link a specific heritage with human failings. So bringing up a Jewish heritage in relation to an individual’s shortcomings felt jarring. Even though later in the book he becomes a somewhat more sympathetic character, the portrayal of Rosedale still left a bad taste. I know we are reading about a different time with different attitudes, but there is this odd feeling that a point of view which aspires to seeing the weakness in others has blind spots of its own.

Ultimately for me, The House of Mirth was like being in the company of an unpredictable Greek goddess. This deity has the power to flit about over the lower human world and make some profound observations in poetic language, while also displaying a rather human and irrational partiality for some people over others.