Archive for May, 2007

Is the process for convicting drunk drivers flawed?

Thursday, May 24th, 2007

It would seem so if Zahir Mohamed’s claim is true that he succeeds in getting 8 out of 10 of his clients off their charges - despite the fact “They are usually drunk.”.

Mr. Mohamed is quoted that “they are a danger to his children” - ” But it’s my job.” Clearly not a WOMBAT for him - “he’s the most expensive drink-drive expert in town” but a WOMBAT for the rest of us.

The other question is - why is the testing to prosecution to conviction process so leaky?

To quote the man who finds the leaks “It is the weakness of the police that we rely on… They just can’t do a thing right… When they carry out the tests they don’t do it properly. It’s purely because they are human beings.”

The weakness is not the human beings - the weakness is in the process. You create a process that works and you analyse process failure to prevent recurrence. Is every failed prosecution analysed so that it won’t happen again? It would seem not.

On a different, but related, note - Candor (Campaign against drugs on roads) look like they have done some interesting analysis on drink-driving and drug-affected driving statistics - but you’ve got to be very persistent to follow their arguments because unfortunately their website is a WOMBAT.

18 months jail for falling asleep, 12 months jail for causing death

Monday, May 21st, 2007

Driver 4 times over the alcohol limit, driving while disqualified - falls asleep at service station - 18 months jail

Driver under influence of drug methadone - kills person on mobility scooter - 12 months jail

Is the “entire penalty regime for driving drunk and/or drugged” an ass (WOMBAT perhaps) as Candor suggests?

Is unnecessary hospital death avoidable? A $1.8bn dollar problem?

Saturday, May 5th, 2007

You go to hospital to get better - but unfortunately 750 people last year didn’t get better, indeed the result of their hospital experience was death and these deaths were “potentially avoidable”.

A further (approximately) 5,000 people “suffered preventable, serious harm ” - from about 600,000 hospital admissions per year. In percentage terms that’s 0.125% for avoidable death and 0.833% for avoidable serious harm.

It always seems cold and callous to express the loss in dollar terms (PDF 32kb) but it does give a common reference that is sometimes easier to appreciate. The last sum agreed in late 1990s was $2.5m per death (a revised estimate of $4m has yet to be agreed). Working with the $2.5m figure that amounts to $1.875bn of avoidable loss annually.

It’s not a new problem - “…what has been in health services for as long as we know.” It’s a classic case of repetitive failure. Worse - there is an expectation of “the inevitability of harm”.

So what is going to be done about this $1.8bn WOMBAT?

Canterbury is conducting a “safe-patient journey” initiative to streamline patient movement at the hospital.

I’d hope that this initiative is a result of a systematic analysis of the root causes of failure and addresses those causes not just the symptoms.

This problem is best addressed by analysing each instance and the root cause of that particular instance - the causes of that instance alone and ensuring that one instance could never happen again. And then do the next one, and the next one and the next one. Each failure is an opportunity to learn and prevent.

Avoidable harm is not inevitable.

OK for judges to sleep on the job?

Thursday, May 3rd, 2007

“Judges, politicians and senior managers who doze off on the job should be treated with sympathy, not condemnation, says a leading sleep expert.” Here is the full article - Don’t blame judges for sleeping on job - expert .

What about truck (or any sort of) drivers, airline pilots, surgeons, air traffic controllers and so on? I’m sure they’ll get a lot of sympathy and not condemation when they fall asleep on the job.