The Instruction That Assumed Too Much
A library volunteer is asked to "process the returns trolley." The written procedure says: "Check item condition, discharge items in the system, then route to shelving or repair as appropriate." The volunteer has used the system twice. On the trolley are 23 books, one with a torn cover and a note saying "hold for repair." The volunteer discharges all 23, including the damaged one, and puts them all on the shelving cart. Later a librarian cannot find the damaged book and the repair note is missing. The volunteer says: "The procedure didn't say what to do with the note."
1. Identify the gap in the procedure that led to the error, and explain why the volunteer's defence is reasonable.
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The procedure lists three steps but never defines the decision points. "Route to shelving or repair as appropriate" does not say who decides, how a repair item is marked, or what happens to a note attached to an item. The torn book is exactly the case the procedure should have covered, and it does not.
The volunteer's defence is reasonable because the note was physical information the written steps did not mention. A new user follows the words they are given; when a real item does not fit the words, they guess. The failure is in the procedure's design, not only in the volunteer's care. That said, discharging the damaged item was still a mistake the volunteer could have avoided by asking.
2. Rewrite the "route to shelving or repair" step as a clear rule that covers the damaged book and its note.
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Step 3 - Route each item:
- If the item is damaged or has a repair note, do not discharge it. Place the item and its note in the red repair tray and tell the librarian on duty.
- If the item is in good condition, discharge it and place it on the shelving cart.
- If you are unsure which applies, leave the item on the trolley and ask the librarian before discharging.
Why it works: it turns "as appropriate" into a test the volunteer can apply, keeps the note with the item, names a destination (red tray) and a person (librarian), and gives a safe default for uncertainty.
3. The librarian wants to prevent a repeat. Propose one change to how new volunteers are introduced to the procedure, and say what it would catch that the current written procedure does not.
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Pair each new volunteer with an experienced one for their first full trolley, with the experienced volunteer narrating the decisions aloud ("this one has a note, so it goes to the red tray").
What it catches: the unwritten judgement calls - what a repair note looks like, where the red tray is, when to stop and ask - that a written procedure cannot fully capture. The current procedure assumes the reader already knows these; a supervised first run makes the assumptions visible and lets the trainer correct them before an error reaches the shelf.