How to do things consistently, correctly and safely? Reading list revolution.

Full order, a revolution to defend safety and correct inventory, Artu? 6? 1 Gwende has profound thoughts on the problems and challenges faced by modern medicine. The book Inventory Revolution also tells the medical experiences of many authors from the medical point of view, but we soon found that the theme of this book is closely related to almost all aspects of the modern world, that is, how to deal with the increasingly complex work. The complexity of the modern world is beyond human control, and any field that requires practitioners to master a lot of knowledge is doomed. From medical treatment to finance, from business to administration, mistakes in life occur frequently, which is shocking. According to Gwender, human errors can be divided into two categories: one is "ignorance fault" and the other is "incompetence fault". "Ignorant mistake" is the mistake we made because we didn't master the correct knowledge, and "incompetent mistake" is the mistake we made because we mastered the correct knowledge but didn't use it correctly. In the book, Gwender lists many medical-related cases for us, from which we can know that the routine of surgery is extremely complicated, and medical staff will inevitably make mistakes of one kind or another. In a stressful environment, no matter how good a doctor is, he will inevitably miss a step and ask a key question, which will lead to mistakes in the operation. Gwende also visited the pilots and construction workers who built skyscrapers and found solutions to complex problems from them. Even super experts need a list, and some key steps need to be written on small cards to help them finish their work. In the book, Gwende also describes how his research team adopted this concept and made a list of surgical safety. At present, the list has been put into use all over the world and achieved remarkable results. "Ignorant mistakes" can be forgiven, and "incompetent mistakes" cannot be forgiven. If we haven't found the best way to solve a certain kind of problem, then as long as people try their best, we can accept whatever the result is. However, if people clearly know what to do, but don't do it, then it's hard not to be angry at such mistakes. We are not ignorant, but no matter how detailed our professional division of labor is, no matter how much training we have received, some key steps will still be ignored and some mistakes will still be inevitable. This list will remind us not to forget some necessary steps and let the operator know what to do. This is not only an inspection method, but also a discipline to ensure high-level performance. The list provides us with a cognitive protection net, which can capture everyone's inherent cognitive defects, such as incomplete memory or inattention. If the right experts get together and have a full discussion as a team instead of individuals, then serious problems can be found and avoided. It is inevitable that a person will make mistakes, but many people may not be able to make mistakes. They know that they can't do it alone, but rely on the collective wisdom. They use one list to ensure that no simple problems are left out and no simple steps are skipped, and another list to ensure that all experts fully discuss difficult and unexpected problems and work out solutions with them. What the top management needs to do is not to make decisions directly, but to urge everyone to actively participate in the discussion and let everyone bear their share of the responsibility. This is the key to the effectiveness of the list. High-level officials should delegate power to frontline rescuers and local officials as much as possible, instead of concentrating power in their own hands. Extremely complicated problems are unexpected, which is one of their basic attributes. For this kind of problems, the traditional centralized processing paradigm is not feasible. The greater resistance to effective teamwork comes from the negative attitude of "nothing to do with yourself, hanging high". The careful division of labor makes team members only care about what they are doing and ignore the problems encountered by other members. This is what we faced at the beginning of 2 1 century: we accumulated an amazing amount of knowledge. Those who master this knowledge are the most well-trained, skilled and diligent people in human society. Moreover, they have indeed made extraordinary achievements by using this knowledge. However, it is not easy to use this complex knowledge properly. From medical care to finance, from business to administration, all fields are full of avoidable mistakes and failures, which makes employees feel depressed and demoralized. The reason for this dilemma is more and more obvious: the quantity and complexity of the knowledge we have already exceeded the ability of individuals to play their functions correctly, safely and reliably. Knowledge did save us, but it also left us at a loss. We need to make a big change to prevent mistakes and failures. This change is based on the existing experience, which can not only make full use of our existing knowledge, but also make up for the inevitable defects and deficiencies of mankind.