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Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors
  1. Joanne F Travaglia1,
  2. Clifford Hughes2,
  3. Jeffrey Braithwaite1
  1. 1Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia
  2. 2Clinical Excellence Commission, Sydney, Australia
  1. Correspondence to Dr Joanne F Travaglia, Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney NSW 2052, Australia; j.travaglia{at}unsw.edu.au

Abstract

In a previous paper we developed a generic disaster pathway model drawing from disaster inquiries in the space, shipping, aviation, mining, rail and nuclear industries. To test our hypothesis that our generic disaster model can be applied to healthcare errors, we ustilised three exemplar cases featuring different types and sources of errors. We found that it is possible to apply our generic disaster pathway to healthcare errors, and to identify the combination of human, organisational and design risk factors which contribute to the severity and speed at which errors occur. We conclude that error pathways provide a useful tool from which healthcare services can learn to appreciate and potentially circumvent or ameliorate errors, prior to their reaching the no-return threshold.

  • Safety
  • human error
  • human factors
  • risk management
  • disasters
  • safety culture

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Footnotes

  • Funding This research is supported by NHMRC Program Grant 568612.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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