(Transcribed from Video at https://www.youtube.com/channel/UCfJpRJg2P6hIvx7JAQsRAxQ)

In the early 19th century, one in four women died in childbirth in hospitals. Actually, sometimes it was up to 100%. That was a paradigm or normal in the 19th century. That was reality, to 19th century people. They didn’t think it could be changed.

Today, the leading cause of accidental death in the U.S. is medical error. Over 200,000 people die each year in the U.S., due to medical error. About 440,000 people, as of 214, were determinately affected by medical error in the U.S. Why is this such a problem? Because human error has a huge stigma and because we as human beings, want to punish people for making a mistake. On top of that, you can get sued if you have a medical error. Dekker in his book, “The Just Culture”, talks about the fact that we have to move beyond punishing people for committing errors and actually learn from them.

From what I’ve seen as a safety professional, looking at over 1,000 different companies, companies set workers up for failure. For example, in the 80’s, I worked for a major oil field service company. A group of workers cemented shut a well, which would cost, in 1989 dollars, over $50,000 to correct. They told me to fire their sorry asses. Instead, I investigated and what I found was that in every terminal, in every part of Alberta, workers had a different technique for setting the valve. The valve was set backwards, which resulted in the well being cemented shut. But nobody trained the oil field workers in how to do it correctly.

As Megger says, you never discipline for a lack of skill, you always discipline for attitude. Poor attitude, not lack of skill. These workers were being punished because they didn’t know what to do and if we had fired them, the underlying cause would have remained uncorrected and would have done it again and again and again. But, the company would have felt good. They fired those dumb ass workers. I’m happy to say they didn’t and a training issue was identified and it was corrected.

Barb Semeniuk is a veteran Safety Auditor and Worker Advocate. Her experience and diligence save companies dollars, and make workers safer while on the job.