The year was 1962, the time of the Nuremberg trials which tried the ex-Nazi personnel for war crimes against humanity including Jews. As the trial progressed one of the main perpetrators of the dastardly war crimes, Adolf Eichmann including others many wrote letters to the commission in charge of these trials, stating that they were merely obeying the orders of their superiors while carrying out heinous war crimes which resulted in the death of more than 6 million Jews in concentration camps including the Auschwitz1. This argument did not refrain the public who believed that there was a moral falling with German people as a whole, who may have facilitated this heinous horror of a crime.
However that same year a Yale social psychologist by the name of Stanley Milgram conducted a series of experiments with 40 participants to test the hypothesis that humans can cause harm to another human, while under the instruction of a superior. In this famous experiment, the participants (called teachers) were directed by an experiment conductor to query another person (an actor, let’s call him a follower) in an adjacent room on a series of questions to which the latter always replied the incorrect answer. For each incorrect answer, they were to administer a series of electric shocks in increments of 15 volts. The follower faked groaning in pain when the volts were increased. The teacher upon hearing the screams of the follower were instructed by the conductor to continue the questioning and not to stop the experiment. Out of 40 participants, only 14 defied the conductor and broke off the experiment in between. However, 65% of the participants of the study were willing to administer 450 volts on another human under the direct supervision of the conductor before the test ended. At the end of the experiment when the participants were asked to rate on a scale of 1-14 on how much they felt the shocks hurt the follower — the result came out to be 13.422.
The controversial Milgram experiment confirmed Eichmann’s assertion that under a superior authority and within the right framework any human can passively hurt another human causing significant and lasting harm. It demonstrates the fact that processes have a bigger role to play in any organization in determining the effectiveness of an individual in any position.
In 2007 the famous actor Dennis Quaid and his wife Kimberly Quaid after the birth of their twins had to send their newborn children to the Cedars Sinai Medical Center NICU to address serious staph infections. They were given antibiotics intravenously and seemed to be doing well a day into the unit. The Quaids left for home for some much-needed rest and checked with the nurses periodically. However, on the 3rd day when they reached the hospital, the staff at the NICU informed them that the nurses had accidentally given their children a blood thinner that was more potent than the one prescribed by a factor of 2000. This turned their blood into the consistency of water where they were literally bleeding out and almost on the verge of death. What happened was that a pharmacy technician took the 10000 unit thinner first and accidentally put them in the same bin as the 10 unit bottles. A nurse in the NICU took the 10,000 unit bottle from the same bin and without confirming the label administered it twice on the twins – one time while the Quaids were in the room with their kids. Fortunately, the kids survived and the hospital spent $100 million fixing their systems and processes to ensure that such an event doesn’t happen again3.
It is easy to blame the lab technicians, nurses or even the German people in these case studies. However if one examines the root causes of some of these events it is clear that systems and most important processes in a company enable or facilitate such deviations. The father of the modern PDCA (plan-do-check-act) cycle was correct when he once famously remarked:
Blame the process and not the peopleDr. William Edwards Deming
- How the Nazi’s defense of ‘just following orders’ plays out in the mind | PBS NewsHour
- AS Psychology holah.co.uk Milgram (karoo.net)
- How a Medical Mistake Almost Killed Dennis Quaid’s Twins (oprah.com)