At the Blood Services, we were audited all the time. We had a quarterly internal audit and biannual external audits from HeathCanada as per regulations and the Federal Food and Drug Administration because we shipped our platelets across state lines to be processed.
So a lot of my time was filled with preparing for an audit, dealing with an audit, or closing the internal and external errors that were caught in an audit. My first external error came from HealthCanada. The amount of time the donor spent bleeding could not exceed fifteen minutes.
We had this huge analogue clock that the donors could see while they were donating. HealthCanada (correctly) realized that reading a clock takes a level of literacy that we can’t assume all donors had, so we were required to switch clocks from analogue to digital so that anyone who donated blood would know when fifteen minutes are up.
So despite this being an error that we didn’t catch internally, the solution was to swap out the clock, change the documents and training procedures as needed, and then show HealthCanada the document with the official sign-offs to show the changes being made.
If we caught the potential mistake, it was internal. If HealthCanada or the FDA caught it, it was an external. Obviously, catching an error that could have lead to a mistake impacting the real world is the ideal. If the error that the institution makes leads to a mistake being made in the real world that impacted something, however, that would be a live error.
A live error is an error that didn’t get caught by the institution or its external auditors that was allowed to cause an actual mistake to happen that could have been avoided given proper adherence to documentation. A centre in Ontario, for example, had to throw out months of donations because a nurse asked the questions using different phrases than the ones that had been mandated.
This wasn’t caught internally or externally as an error before it impacted members of the public. There is nothing worse in an institutional setting than a live error. Because the Centre hadn’t trained its Persons properly, all the work and effort involved in donating and processing the blood for Canadians who needed it was thrown out because if one mistake was made, any mistake could have been and the centre had to do a hard restart.
The UBC, on the other hand, turned over all its policy binders to its University Counsel and asked “which ones are the ones that we have to legally care about, so we know we can ignore the rest of them entirely.”
And the lawyers committed their first live error by not saying, “Woah, dude. This is a policy matter. We’re hammers trained to deal with legal nails. You need a UBC Person trained to deal with a bunch of loose screws.”
Instead, they decided that not having any training in policy wasn’t enough reason to not give their legal opinion of the necessity of policy adherence. Mark Crosbie truly thought that his limited knowledge of complicated policies well outside his legal expertise trumps someone with their own level of expert knowledge on the subject. This is a perfect example of a live error.
And good luck to him when he tries to explain why he decided the UBC doesn’t have to follow its own policies to people who aren’t UBC Persons looking for a way to “legally” ignore them.
When I wasn’t working around audits and their schedules, I was listening to my staff that had a hundred years of collective experience I didn’t have. Whenever they came across a situation where a mistake could have been made even with the policies in place, I worked with them to create new procedures and training so that the almost-mistake could never happen again if someone with less experience than my staff came across the same situation and didn’t know what to do.
To any competent trainer, the fact that a live error could have happened is an instant code red situation. The UBC “training department” has a lot to answer for if they weren’t trained enough to know no lawyer has the authority to tell them policies don’t matter if the UBC decides it doesn’t want to follow them.