What Happens When Systems Fail

Estimated reading time: 6 minutes

When systems depend on human vigilance, they will fail. Build a process you can trust. Don’t look for past precedents when there may not be any.

The story

It was a particularly busy day at the doctor’s office. It was a small practice of 2 pediatricians. One nurse was out that day and they were short one admin who was on vacation. Patients who had put off visits seemed to all be coming in at the same time. The office was shorthanded. Papers were piled on the fax and post-it notes dotted every monitor in the office.

The fax machine began its high tone whirring as yet another fax rolled out onto the pile that accumulated from the previous day. The nurse grabbed the pile of papers that had accumulated on the fax from yesterday and began on the bottom with the oldest. This first one caught her attention immediately. It was a lab report for a 9-year-old boy and the values were not good.

It was the result of a complete blood count which looks at red blood cells, white blood cells, and platelets. The one number that jumped out at her, like a flashing red light was the white blood count. White blood cells play a vital role in fighting off infections, viruses, and other attacks on the body.

When your body is fighting infection or disease the white blood counts go up. A high WBC count suggests that the body is trying to fight off an infection or disease. While White Blood Cells are fewer in number than red blood cells a normal WBC is about 8,000 per cubic ml of blood. When the body gets an infection the counts may climb to 15,000 to 18,000. If you are extremely ill your counts could get as high as 50,000 per cubic ml.

She stared at the report, blinked, inhaled, then forgot to exhale.

The white blood count was 183,000. The fax was dated and time-stamped more than 30 hours ago. It had been sitting there for two days.

She ran to the doctor who grabbed the phone and immediately called the parents.  He swallowed his panic. “Crap, this is going to be a malpractice case.  How could this happen and make me responsible for this chain of screw-ups.” He exhaled before anyone answered.  He projected his professional doctor’s calmness while simultaneously messing in his pants.  

“Hi, this is Doctor Miller.  We got your son’s blood tests back.  I would like you to take him to the emergency room at Children’s Hospital.  (Pause). When?  Immediately.  Take him now and no you can’t stop for breakfast. Call me when you get there, and I will set up a consult with the doctor on call.”

He hung up the phone positive he just freaked out the parents.  There was no time to waste.  He couldn’t think about that.

The boy in that report was my son, an event etched in my mind 14 years later.   

Where the system failed

Laboratory Medicine Best practices established by the CDC state that labs must have procedures in place for promptly conveying critical results to the doctor. A critical value is any imminent life-threatening result requiring immediate physician notification. This white blood count was a critical value. The lab should have called the doctor immediately. They sent a fax. It sat on the fax machine overnight.

When he arrived at the hospital he was diagnosed with “A.L.L.” acute lymphoblastic leukemia. He was a slow responder and even on chemo his counts skyrocketed to 525,000 /ml before the drugs began to work and they dropped to a “normal” 85,000. 

They sent us home and we converted our bedroom into a makeshift hospital room.  We administered drugs through the PIC line in his arm for the next 3 years.  After five years he was finally declared to be in “remission.”  You’re never cured.

What does this have to do with your business?

Everything.  To make money, have a life, and run your business, whether it is a one-person business, or you have 500 employees certain fundamental principles remain the same.

Our leadership and entrepreneurial lives are constantly facing unforeseen problems that can be triggered by broken systems.  We cannot see them coming, they escalate rapidly and can become a grave threat. Covid 19 is a perfect example!

This malevolent force was called “institutional malaise.”  It wasn’t the failure of any one person or institution. It was simply responsibility without authority. Too much work and not enough time. A perfect storm for how bureaucracies and systems fail.

What happened

COVID-19 was a worldwide catastrophic event that mobilized health organizations across the globe. While this was helpful it was not completely effective. There are three C’s in effective change leadership… Communicate, Collaborate, and Commit. It is not likely that anyone will agree that this happened in the early stages of Covid as the virus spread exponentially. Some would say it still has not merged into a cohesive effort. 

The result

The problem is that human brains, and by extension, complex organizations, are not wired to grasp exponential growth. COVID-19 was certainly exponential as it exploded around the world. Complexity is not limited to large organizations and governments.

To understand exponential growth, consider the following representation of how fast the COVID-19 virus spread.

On March 2, 2020, there were 15 new reported cases per day.  By April 3rd there were 32,318 new cases per day.  By January 2021 there were 201,784 new cases in one single day. How do you manage this explosion?

A small organization can be complex without any sustainable process. Exponential growth can result in change feeling initially slow and incremental. Then surprising when it later appears ‘suddenly’, becoming rapid and overwhelming. Like COVID-19.

Entrepreneurs and business owners must be vigilant to the potential of unforeseen crises stemming from dysfunctional systems. Failing to recognize these vulnerabilities can lead to a crisis spiraling out of control, endangering the stability and viability of their enterprises. It is imperative for them to proactively address and fortify these weak links to ensure resilience in the face of escalating challenges.

Conclusion

If we depend on our systems or processes to catch things, what happens when they don’t? My son nearly died by depending on human vigilance. Many businesses have gone bankrupt depending on human vigilance. Every leader today must make decisions based on rapidly changing scenarios. And it requires non-linear thinking.  And scenario planning.

About the Author

This article chronicles the real-life experience of Paul Childs and his young son at the age of nine. Paul is one of the leading experts on patterns of human behavior for High-performance leadership.  He is one of the top thought leaders in leadership development. He has delivered more than 20,000 hours of one-to-one coaching and has facilitated over 300 meetings with executives and leaders from all over the world. You can contact Paul on his website at www.businessmastery.com

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