A wee story about mistakes

'Father Christmas needs a wee' is a classic book that teaches kids how to count. It's all about something that secretly fascinates: how close do others get to the embarrassing social mistake of wetting themselves? It's just a story but it has inspired Dom Furniss of UCL to tell us some similarly festive, but true, stories about his friends. Read on and you may learn something useful about avoiding nasty accidents.

Going, going, gone

Rob was heading home from London after the office Christmas party. Emma, one of his work friends, offered him a lift home. She was in the passenger seat, her husband was driving and he was in the middle of the back seat with a girl from work on either side. He still had a can of drink to finish, but maybe bringing it wasn't such a good idea. Not too long into the journey he began to feel the need to wee! It wasn't that far so surely he'd be able to hold on, though.

Unfortunately, the feeling grew stronger quite quickly. Beads of sweat started to form on his brow as he fought to hold the pee back. The others in the car were chatting and laughing. He didn't want to be a hassle and ask them to pull over, and besides they were on a motorway, so it'd be difficult anyway. Weighing everything up Rob thought the best course of action would be just to let a little bit out, which would relieve the pain and buy him time to have a proper wee when he got home. Anyway, you can probably guess the rest... he sat there and watched his plan go increasingly wrong as a dark wet patch grew and grew. Once started nothing could stop it.

The relief paled into insignificance as the gravity of the awkward social situation started to sink in. He was in his colleague's car, sat between two other people from work, and without a whimper he had wet himself. However, this will surprise you: after such a stupid mistake Rob now performed an amazing act of genius to save the situation - he faked his elbow being pushed by one of the girls and dropped his can of drink into his lap. She apologised profusely, he told her not to worry. He smiled smugly as he finished the journey not as the perpetrator of a pee crime but rather as the victim of an unfortunate spillage.

The knowledge

What can this tell us about the science behind human error? Well this is an example of a 'knowledge-based error'. They happen when a person has some wrong or missing knowledge about a situation. In this case Rob should have known that you can't just let a little bit out. How could he not know? Surely, everyone knows that if you're dying for a pee, once you pop you ain't stopping until it's finished! The trouble is something that is obvious to one person can be unknown to another. If Rob had the correct knowledge he would have chosen a different course of action. Unfortunately he didn't.

Preventing this kind of problem is about making sure people are well trained and have all the knowledge they need to do the job. This is also where learning from mistakes is vital. If you make a knowledge-based error and understand why it happened, you should never make it again. You now have the correct knowledge. Ideally, others should learn from your mistake too, though, if you don't hide it like Rob did.

In work situations, once we know of a problem, we can train people so they have the knowledge to choose the right courses of action. If rather than looking to blame or shame when someone makes a mistake we look for lessons to learn, we can prevent the problem happening to anyone in the future.

This is especially important with medical technology. Take the tragic case of the patient who recently died because of taking a hot bath. They had a special patch inserted under their skin that delivered the drug they needed in a low-hassle way. What they unfortunately didn't know was that a hot bath increases how much drug is delivered by the patch. If we raise awareness of this danger it will hopefully prevent others patients doing the same. A tragic accident like this can also lead to a review of wider issues than just the particular thing that patient didn't know. For example, reviewing how patients are told about this sort of safety information more generally might lead to other kinds of accidents being avoided.

That patient new nothing about the risks of taking a hot bath. But suppose they did know. It's still entirely plausible that they could take a hot bath having just forgotten that they shouldn't. Part of the advantage of these patches is that they can be implanted then virtually forgotten about. What is supposed to be a blessing but turns into a curse. You mustn't forget about the patch if you are thinking about a bath. This is a completely different kind of error to a knowledge-based error. It's called a slip error and it needs a different kind of solution to prevent it. It needs innovative design not just the spreading of knowledge, but that's another wee story.