There was, Carter thought, a downside to experience. “Experience is making the same mistake over and over again, only with greater confidence,” he said. The line wasn’t his, but he liked it.

“Nothing big happens until you close the schools. It’s not like anything else. It’s like a phase change. It’s nonlinear. It’s like when water temperature goes from thirty-three to thirty-two. When it goes from thirty-four to thirty-three, it’s no big deal; one degree colder and it turns to ice.”

One way to reduce medical error, he thought, was to redesign the environment to make it more difficult for bad things to happen. “You cannot put a 120-volt plug into a 240-volt outlet,” he said, by way of analogy. “Why? You can’t do it! You can’t fit it in!” In medicine there were too many 120-volt plugs that fit into 240-volt outlets.

“I never told them what I would do,” said Carter. “I was allowing them to open the curtain and take a look. You see so much. If people would just spend their time and observe. You don’t need any advanced degrees.”

He also set out to learn everything he could about the inner workings of the human mind, and where and why it was prone to err. He found a book called Human Error, by a British psychologist aptly named James Reason. “It was like reading the owner’s manual of the human mind,” he later recalled. “Not the usual owner’s manual, but an owner’s manual th

Henderson might have left it at that, but for some reason he couldn’t. A month later he wrote a scathing three-page, single-spaced reply. It bothered him that this professor held himself out as a student of battlefield decisions without understanding their most important quality, uncertainty. “I have found that there is an order of magnitude differ

To Richard’s way of thinking, the fact that the decision happened to have worked out did not mean it was the right decision; in a funny way, it was alarming that it had worked out, as it created a false sense of confidence in the process that had rendered it. In late September he noted that others sensed this, too. An idea that has gained currency

“Deciding on a swine flu program is like placing a bet without knowing the odds,” the authors concluded, without acknowledging that not deciding on a swine flu program was also placing a bet, also without knowing the odds. The odds were never knowable. The authors never considered the interesting counterfactual: Given the uncertainty inherent in th

But the shift inside the CDC that had begun with the Swine Flu Affair had led it to become a different sort of place. “Now I understood why the CDC was so admired,” said Charity. “It was because of people like him.” But Sencer had also exposed the price of bravery. After Sencer—or after Foege—the CDC’s relationship to disease control had changed in