Systems Thinking

Recently I caught myself, after preparing a bowl of raisin bran, about to put the milk in the cupboard and the cereal box in the refrigerator. Another time, I remember my mother trying to unlock a car that was not hers in a busy parking lot. Researcher and author Don Norman calls these types of errors “slips.” A slip happens when a person intends to do one action and actually does something else. Many times, the right action (putting the milk away) is performed on the wrong object (the cereal box). In health care, a similar example would be a nurse hanging a bag of heparin when intending to hang a bag of norepinephrine. Health care slips may have more significant consequences than spoiled milk.

When slips happen, does it mean that we are not intelligent, competent, or responsible? Not at all, according to Norman. He states, “Humans err continually;...