Newman's Notions | December 13, 2023 | FREE
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Small oversights can line up to cause a major problem.

Last May, I was flying to Palm Springs for a hospital medicine CME course. I thought I might as well go, since I was a speaker and the course director. But despite the allure of a week of medical education in an attractive location, I was reluctant to travel because I had been sick for several days with a gastrointestinal ailment and hadn't been sleeping well. The 90-minute drive to the airport in Minneapolis exhausted me, and as soon as I was in my seat on the plane, I was asleep, even before takeoff.

Illustration by David Rosenman
Illustration by David Rosenman

To make matters worse, I wasn't even close to my destination when I landed at the airport. I wanted to visit my daughter Emily in L.A., and I thought I could combine that excursion with my work trip. Sadly, I hadn't really thought this through, as her apartment was over an hour from LAX, and the conference course location was even further, about two hours on the road.

I dragged my sorry corpus through the airport, cursing my poor preparation. But I had to rise to the occasion. I had my car reserved and I used all my travel tricks to get behind the wheel as soon as possible. Soon I was in a fairly comfortable ride, bags loaded. I took a deep breath and pulled out my phone to load some directions. The estimated travel time to my daughter's apartment was three and a half hours, due to the legendary L.A. traffic. Depressed, exhausted, uncomfortable, and frustrated, I pulled to the lot exit, papers and license in hand for the attendant.

As if things weren't bad enough, he looked at me and shook his head. “Sorry, buddy, your license is expired.” It had expired on my birthday two weeks prior. I tried to cajole, plead, beg, even bribe my way through the gate. All to no avail.

Then I tried to renew my license online, but that was not possible since it had already expired. I had only one option left. I pulled out my phone and ordered a ride. Eventually it came. I slumped in the back seat and soon was out cold. No time left to visit my daughter; I'd have to go straight to Palm Springs. Several hours and $300 later, I was at my conference hotel.

Poorer but more rested, I thought back on the whole situation. In retrospect, driving would have been very dangerous: Heavy traffic, unfamiliar roads, fatigue, and frustration are a deadly combination. And how is it that my license had expired? Clearly, an error had occurred. Was it my cognitive lapse or a systematic issue? In Minnesota, a driver should receive a warning letter 45 days prior to a license expiration, but either I missed the postcard or it was lost in the mail. (Just like so many of the checks I send to pay my bills.)

What if this had been a series of medical mistakes and the expiration of my medical license? In 1990, James Reason described the Swiss cheese model of error, in which scattered holes occasionally line up to let problems slip through our safeguards. This situation was cheesy for sure.

I should have known the license was expiring, but I was sick, distracted, and generally clueless. A notification should have been sent, but either it didn't arrive or I missed it, perhaps because I've been trained to expect multiple alerts for every problem. When I book a bed and breakfast or a flight, I get eight notifications, but for something important like a driver's license, there's just a postcard.

This adventure was a $650 lesson by the time my trip was over, but the errors could have lined up to do much worse. Luckily you can fly with an expired license (for up to a year), so I got home. As I prepare for the trip I'm taking later today, I'm reviewing the checklist I created after this debacle—valid license, credit cards, cash ... Wait, where's my wallet?