Scratch Tickets & Independent Double Checks

In Human Factors, Interuptions, Multitasking, Normal Accident Theory, Patient Safety, Teamwork on September 19, 2010 at 2:34 pm

I played tennis this morning with a friend. On the way home I thought I would stop at the supermarket to pick up some snacks for the Patriots game today. I realized I forgot my debit card (ah, the limitations of the human memory). Looking for alternate forms of payment, I found winning lottery scratch tickets in my glove compartment.

I quickly added them up (3 of them) and confirmed that …they totaled enough for what I intended to purchase. Just a note: I am not a good scratcher. I only scratch enough of the ticket to just barely reveal a winning prize amount.

On the way to the supermarket I passed a gas station and decided to stop for gas since I had about an eighth of a tank left and the price of 1.519/gallon was pretty good. As I was getting out to pump, my friend asked if I wanted her to go inside and cash the tickets to save time at the grocery store. Sounded great to me!

She quickly rifled through them (the 2nd check) and said “$35 total, does that sound right?” I hesitated for a moment because when I cash in tickets the total is almost always a multiple of 10 (gut feelings or hunches should ALWAYS be a sign to investigate more closely). But I remembered there was a $15 win in the pack so it made sense. “Yeah, sounds right,” I confirmed.

A few minutes later, I finished pumping and my friend came out in a state. “Thanks alot, ” she said, “I just had a huge argument with the guy in the store. I thought he was trying to rip us off by saying the tickets only totaled to a $30 win.”
All of a sudden the process of my initial count came back to me… “Oh..there was a $15 prize, a $10 prize and a $5 prize…yeah $30.”
She looked at me and said “You confirmed $35!”
I looked down sheepishly. “That’s right, I did. I am sorry. ”
She accepted my apology but made a few more comments about how embarrassing it was.

The 3rd check by the cashier in the store caught the error so no mistake was made. But this was a near miss that caused friction between my friend and the clerk as well as with my friend and I.

Many processes of independent double checks in the hospital hopefully keep the patients safe. But as you can see, the two checks do not ensure accuracy. And even when there is a near miss and no one is harmed, what does the process do to colleagues? Do they become embarrassed? Do they lose trust in each other? Do they lose the trust of the patient if the patient is the third party who discovers the error?

The reporting and systems analysis of near misses is the foundation of any safety and quality program in an organization.

There will be lots more to come on this blog about near misses and the human factors involved in this and in the safety concept of independent double checks. Redundancy can be a double edged sword in terms of providing safety.

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