Amy Edmondson

speaker

344 appearances 1 recordings 1 series first heard Aug 2026 last heard 3 Aug

Amy Edmondson’s voice in public audio — every appearance, attributed to the second.

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recordings per month · last 12 months

Recordings per month over the last 12 months — 1 in all, peaking in Aug 2026 with 1.

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Hidden Brain · Making the Most of Your Mistakes · 3 Aug 2026 podcast

Ooh, let me look into it.

Let me see what I can learn.

So it's tragic, but there are no bad guys here.

That's right.

And the Swiss cheese metaphor comes from an error theorist named James Reason from the UK.

And he uses this metaphor of Swiss cheese to try to explain the notion of complex failures.

He says, you know, when your cheese has air bubbles in it, those are in a sense defects in the cheese, but they're not problematic until they line up and make a tunnel.

Just rarely happens, but when it happens, then the error goes all the way through.

So...

In the case of this morphine overdose, I was able to analyze seven factors contributing to the accident.

So to begin with, there had been an overflow in the intensive care unit where most post-surgical patients go, and this boy had just had surgery.

So he was sent to the regular medical floor which has less specialized staff.

So that's one factor.

Now, that by itself would not lead to this kind of overdose.

But unfortunately, there was a brand new nurse right out of school who was assigned to take care of him.

And then there was an infusion pump that's used to deliver this pain medication.

And it happened to be located in a rather dark corner, making it a little harder to see.

And the nurse also hadn't done this kind of programming before.

So he asked for

a colleague to help, she stopped by to help but she didn't do her calculations independently, she just looked over his shoulder and verified his.

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