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Many people working in health care know very little about the human and organisational precursors of error. But, as technology advances and both workloads and complexity in health care increase, the risk of error and adverse patient outcome grows. In the face of these trends, public expectations of health care are rising and tolerance of error is diminishing. The paper by Professor James Reason, although focusing on anaesthetic mishaps, contains generic information that should now be considered a required part of the undergraduate and postgraduate medical curricula.

Learning from others

Health care has been characterised by its “silo” thinking! All around it in the community other professions and occupations—such as aviation, nuclear power plant operations, military command, fire prevention, rescue organisations—have developed and employed successful safety measures that are directly applicable to many healthcare activities. Until recently, medical workers took little notice. But we are learning now via the psychology pipeline. For example, some disciplines—led …

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