Well-designed systems reduce errors and save lives

Or, actually, the article I found is called How Hospital Design Saves Lives:

The report emphasized the benefit to be had from focusing not on individual people making individual mistakes, but rather on the systems themselves. Health care, the Institute of Medicine said, had to learn from industries such as aviation, nuclear power, and construction that dramatically increased safety using “systems thinking,” looking holistically at failures, rather than identifying a single weak link.

For health care, that meant replacing individual blame with collective responsibility. Improvements are already visible. In June, Dr. Donald Berwick of the Harvard School of Public Health announced that an estimated 122,300 lives had been saved in just the last 18 months, as a result of changes—ranging from improved hand-washing to establishing an organization-wide mandate for safety—recommended by the “100,000 Lives Campaign” sponsored by the Institute for Healthcare Improvement, a Cambridge (Mass.)-based nonprofit.

A few benefits from better systems:

  • Consistent work places, such as surgery rooms where the “right” is always on the right, reduce predictable errors. Perhaps surgeons could also use terms like starboard and port for the human body? Although I’d be nervous if I heard a surgeon start a procedure with “anchors a-weigh!”
  • Clean air reduces infection rate. Seems pretty obvious for a hospital, but apparently this wasn’t given appropriate priority in past systems.
  • Natural light improves mental health. I always wonder about hospitals that keep all their fluorescent lights on but the shades are drawn during the daytime. Perhaps heat-shielding or even solar-absorbing windows would cut down the negative effects of natural light while letting the positive remain
  • Reduces cost of maintenance
  • Increases likelihood of “green” practices, which further reduces harmful exposure and impact to the environment

Interesting to see tangible health and energy benefits from removing bugs in health-care systems. Of course there is some question of what it really means to be “evidence-based” since one person’s evidence might be seen by others as faith — a system of resolution is necessary.

EMC acquires RSA for $2.1bn

Whoa, that’s a lot of tokens. Is the price justified? I must have been asleep when this happened, or at least no one has made much noise about it. The past few token systems I’ve planned or managed on haven’t touched RSA, so maybe I was just out of the loop. Anyhow, apologies for the delay, but here it is:

…the world’s biggest maker of data storage equipment and software, on Thursday unveiled its latest acquisition when it agreed to pay $2.1bn in cash for RSA Security …

In a statement on Thursday, Joe Tucci, EMC chief executive, said: “Information security is a top priority among executives around the world, and it has become an inseparable attribute of information management.”

Correct, the attribute of security is inseparable from information, but that is a bit like saying the attribute of safety is inseparable from automobiles. I could make an analogy to financial risk instead of cars, but that might get confused with another top priority among executives around the world:

RSA earlier this month revealed that it was one of several dozen companies that had received a subpoena from the US attorney’s office related to stock options grants.

The acquisition seems to be aimed at the “secure storage” sector that Symantec-Veritas was supposed to be leading. Yet, these giants are so sloth-like and pricey when it comes to delivering solutions that I believe we really need a visonary or a start-up like StrongAuth to move things along. In fact, I suspect secure storage hosted solutions via big content providers will be more likely to catch on than direct-to-consumer products, so a big challenge for EMC will be getting buy-in from highly technical decision-makers who (should) push for thin margins and easy interop. Then again, if the buy-outs continue and competition stagnates at the enterprise level, Apple’s new archive product could prove to motivate the consumer secure storage market first.

Color vulnerabilities

I find it somewhat amusing to see folks talking about the security rationale behind a black and white image of a new music player:

The reason the shot is in black and white is because Microsoft assigned a unique color scheme to every Zune prototype in existence right now—all 150 of them—so any leaks could be traced to the employee who leaked it. We don’t want to be jerks and get anybody fired.

Interesting, but a bit hard to imagine that was the real motive for the color scheme. Basic photoshop trickery seems like an obvious gap, no? In other words the greyscale conversion is as much a statement as an example because color balance changes in any photo-editing program would dissolve the identifier (e.g. you could make a red player green, or a pink one orange). A color shift in the right direction could perhaps even throw Microsoft off the trail of the real leak, if they really did intend to use colors as a control.

And that just reminds me of the issue with expecting color controls to work for those who are colorblind (or failing to test in a colorblind environment). For example, in 2002 a plane crash was thought to be related to a co-pilot that could not distinguish colors:

Federal rules require that pilots see colors well enough to distinguish between red and green, which are used in instrument panels and warning lights. Frye passed vision tests as a Navy pilot from 1981 through the mid 1990s, but failed a color test when he got his airline license in 1995 because of “a mild red-green defect.” The Federal Aviation Administration gave him a waiver because of his “demonstrated ability” as a pilot.

After the Tallahassee crash, the NTSB had Frye’s vision tested at Brooks Air Force Base in Texas. Doctors found he had a “severe” problem that could make it difficult to interpret red and white warning lights like the ones at the Tallahassee airport.

But William Walsh, captain of the FedEx flight, told the St. Petersburg Times this week the lights indicated they were making a safe descent. “Everything visual that we saw told us we were on glide path,” he said.

If you read the story, it looks like the lights were actually red and white. Not sure how things turned out, but I thought it interesting that the pilots’ lawyer tried to make an argument about the lawnmower:

Maciejewski, the attorney for the pilots, said the NTSB tests were inadequate because they did not replicate the nighttime conditions of the flight. He says the PAPI lights might have malfunctioned because of “contamination” on the lenses or because they had been banged by an airport lawn mower.

Maybe the lawnmower was colorblind too.

You’re only vulnerable, everywhere

Today John Stewart exposed the soft underbelly of CNN’s “Target USA” all-day program.

I’d quote the best lines here, but that would spoil the fun…

Watching Stewart is like seeing the best of the best stories of the day, but for news. Take, for example, his coverage of the “Bush reads The Stranger” story. What’s next, Bush reading poetry? There’s something deeply ironic about Bush reading up on “anti-dogma” philosophy, beyond the fact that the story of The Stranger is strangely appropriate to describe Bush’s agenda. Some have also pointed out that Bush Administration looked to Camus in his Feb 2005 “New Era in Transatlantic Unity” speech. Note the State Department’s byline: “Bush says Israeli-Palestinian settlement ‘within reach'” and the fact that Bush mentioned the path to a peaceful Lebanon in that speech. Perhaps he felt like he needed to go back and re-read Camus since things did not work out quite as expected.

Speaking of irony, Bill Moyers once suggested that the difference between journalism and poetry is freedom. Guess which one he thought was more grounded:

In discussing less politically charged subjects, Nye asked Moyers for his thoughts on poetry, since he and his wife, Judith, produce public readings every year. Moyers said poetry is the greatest outlet for the sensual, religious, erotic, intellectual and spiritual experiences in life, and that, although he has only written one poem in the course of his life, he greatly appreciates the art.

“Poetry is like going to church,� he said. “It is like finding a voice that says, ‘This, too, shall pass.’�

Moyers said his profession did not offer the same creative freedom that poetry could.

“As a journalist, you are not quite as much at liberty as the poet because you are supposed to be tethered to verification,� he said. “We’re supposed to offer evidence, and we’re supposed to have deep respect for the facts. You don’t speculate in public domain. The best journalists are cautious in that respect.�

However, Stewart clearly shows through his brilliant comedy that journalists on Fox and CNN are paid handsomely to speculate in the public domain. Meanwhile, poets seem more often to be the ones who wrangle with the facts of life (i.e. slam contests or even blogs). Thus it seems almost probable that a national poet would provide the public more sincere verification and tangible evidence than many of the national news reporters.

Oh, and for even more fun with security and the news, Stephen Colbert has some great tips on how to protect your identity.