RE: Focus on personnel, not system

["Nimon, Harry H SITI-GRCA" <hnimon@Shell.Com>]

Bob wrote: Isn't what you describe an example of 'Groupthink'? And if this
is the case is work-place culture part of a systemic rather than a problem
with an individual?
What was that about instituting training and isn't this a way to change a
culture, and being hard on the problem and soft on the people

Interesting thought however the policy was explicit in situations such as
this.  
Also, these nurses are certified to be able to recognize indicators of
bodily activity so that if the patient is going south, they can immediately
take remedial 

action to stabilize the patient (system) to bring it back to 'control.'  The
problem I experienced happened over the course of 12 hours.  They would come
in to take my vital signs (statistical sampling) every 2 hours and would
check the 'indicator' of 'production.'  This production indicator was NOT
producing the quantity it should have for the amount of raw material input.


With the human body, 1000ml input per 3 hour period MUST result in
1000ml/period output or there is something drastically wrong.  My output was
150ml/period over this 12 hours.  This was dutifully recorded...and never
reported to the doctor per standing orders.  The supervising nurse is
charged with monitoring the floor nurse's activities as a backup check to
this and other processes.  This also did not happen.  That, to me, is not
'group-think' but rather simple 

dereliction of duty.  Where lives are at stake, short-cuts cannot be
tolerated.

Harry Nimon