Lesson 2 I thought: Rules create safety.
I learned: Rules and breaking the rules create safety.
Safety is a continually emerging property of a complex system
- its more like driving a car than baking a cake. People
figure out the details if you let them. Breaking the rule is
the adaptive response of an intelligent workforce involved at
the sharp end of health care. In the violation of the rules is
the next level of information about what to do to make a
person safe. Rules should be more like instructions for driving
a car allowing the driver to adapt to current
circumstances than a point-by-point recipe for baking a
cake. The people at the sharp end will figure things out if
given guidance, but they will be guided wrong if the rules are
over-enforced. Overspecification is a problem in safety.
(from the 2001 Annenberg III conference)