We now know that most serious medical errors – including the biggies like wrong-site surgery – stem from communication failures. But these types of failures aren’t unique to medicine. Here’s a sidesplitting one from the cake-baking business.
Thanks to John Nelson for pointing this one out to me, from the blog “Cake Wrecks.” (Yes, a blog devoted to chronicling “when professional cakes go horribly, hilariously wrong.” What did we ever do before the Web?). The story is hard to verify, but – if medical errors are any judge – I’m guessing that it’s true. Here goes:
[Answering phone] “Cakey Cake Bakery, Jill speaking! How can I help you?”
“Hi, I need to order a cake for my boss. We have a photo of him playing golf that we’d like to put on it, though – can you do that?”
“Of course! Just bring the photo in on a USB drive and we’ll print it out here.”
“Great, I’ll bring it by this afternoon.”
A while later…
“Hey, Jill, what am I putting on this cake?”
[Calling from the back room] “Oh, check the counter; I left the jump drive out for you there.”
“Really? This is what they want on the cake?”
“Yeah, the customer just brought it in.”
And here’s the resulting cake!!!
[The original blog post is here, accompanied by nearly 200 comments!]
This enters my Pantheon of Screw-ups, not quite reaching the pinnacle – that position is securely occupied by the poor guy who found himself being mistakenly interviewed on live BBC television (about intellectual property law) when he showed up for a job interview. But it’s pretty good.
All these cases share similar recipes: two-parts sloppy processes mixed with one-part “it must be right” (the most dangerous words in any complex organization, by the way), often sprinkled with a few tablespoons of time pressure. It’s a recipe that is also common to most medical errors.
The difference, of course, is that their glitches wreck cakes, while ours can harm and kill people.