Tuesday, October 8, 2013


Lesson from a doctor

According to an article in the San Antonio Express-News’ mySA site heded Poor penmanship costs doctor $380,000, “A local physician whose illegible handwriting led to the fatal overdose of an elderly patient was ordered by a civil court jury Thursday to pay $380,000 in damages to the woman's family.”

While most Enterprise Risk Management (ERM) and Business Continuity/COOP practitioners eschew the pen in favor of a keyboard, the point of the article, at least as this practitioner sees it, is the necessity to make certain the audience gets the correct message.

It is not the audience’s job to try to interpret the practitioner’s words; it is the practitioner’s job to communicate to the audience in a manner the audience comprehends.

By the way, the operative word is “comprehend,” not “education” or “position.” Neither necessarily equates to comprehension of a specific subject.

According to the San Antonio paper, the doctor “changed his mind about the dosage, intending to increase it (from 10) to 20 millamoles(NB), testimony during the weeklong trial indicated.

“However, instead of scratching out the original amount on the form or starting over, he attempted to write a “2” over the “1,” the doctor acknowledged.

“The result, witnesses said, was a misinterpretation by nurses and pharmacists that the doctor had ordered 120 millimoles — a dosage described by plaintiff's attorneys as very obviously fatal.”

Most practitioners find they must communicate with multiple audiences – very senior management, middle/line management, and the folks in the trenches. Add to that that the folks in the IT trench may not have the same vocabulary as the folks in the HR or production trenches.

Fortunately, there are ways to mitigate the problem.

One way is to let someone else create the plan documentation. At the same time, this can exacerbate the problem; instead of the scrivener getting the information directly from the source, the writer gets it second hand from the practitioner.

    There was a game children played when I was in primary school. Kids sat in a circle. One child whispered a word or sentence to the next child. The second child told the third child. This continued until the last child “got the word.” That child was asked to tell everyone what the child thought the first child said. Then the first child said what really was said. The two responses never matched.

No matter who creates the document, each section of the document that covers a functional unit – facilities, HR, IT, Production, Purchasing, Shipping/Receiving, etc. – must review its portion of the document.

If – and most do – a section overlaps other sections; e.g., a process being handed off from Section “A” to Section “B” and, after Section “B” completes its tasks, hands the process to Section “C,” the related sections must review their parts of the Section “B” document.

If there are major revisions, the revised sections need a follow-up review by the sections’ Subject Matter Experts (SMEs).

Practitioners need not be SMEs in all fields, nor should they be expected to be an SME in anything other than risk management. I understand a little about IT, but I depend on the IT SMEs to make certain I understand the processes if not the terminology.

It’s a good idea, when gathering information, to note the source and the source’s contact information. The source for process information ideally will be the person who performs the process.

    Keep in mind that the process may be different when recovering from an event than normal, day-to-day operations.

Documentation that is incomplete, poorly structured, or poorly worded is worse that no documentation at all.

The practitioner – or the professional scrivener – must keep foremost in mind the audience’s requirements and the audience’s technical vocabulary, be it HR-speak or IT-jargon.

Anything less and the practitioner could end up in court.


millimole (mmol)
a unit of metric measurement that is equal to one thousandth (10-3) of a mole. It is the amount of a substance that corresponds to its formula mass in milligrams.

the amount of a substance that contains as many elementary entities (atoms, ions, molecules, or free radicals) as there are atoms in 0.012 kg of carbon 12 (12C), i.e., Avogadro's number, 6.023 × 1023, of elementary entities.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.


If I wrote it, you may quote it.

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