Travaglia et al's recent paper in BMJQS[1] alongside their earlier work[2] provides some valuable insights into research which has been carried out on large-scale disasters and accidents. This type of work has the potential to move patient safety away from a focus on individual error and towards the adoption of a wider and more inclusive perspective on the failure of whole health care systems such as hospital.[3] That said, it is perhaps all the more surprising that their work appears to have overlooked the contribution of one of the landmark studies of the origins and preconditions of disaster, namely the late Barry Turner's work on Man- Made Disasters.[4-6] Turner carried out a detailed analysis of 84 British accident inquiry reports from 1965-1975 across a range of industries. One outcome from his analysis was a stage model of the factors underlying failure and a description of the preconditions for disaster in what Turner called the "incubation period" immediately prior to the disaster. During the "incubation period" a chain of discrepant events, or several chains of discrepant events, develop and accumulate unnoticed. These types of events might include oversights, failure to follow safety procedures or errors which go unnoticed. In combination these events raise the potential for an accident or disaster to occur. Turner's work is also important in terms of the stress it placed upon adopting a systemic approach towards accidents and disasters. The systems approach emphasizes the need to understand in fine detail the nature of organisational processes and the how connections between these processes and other system levels (e.g., individual, group) emerge, interact and consolidate over time. A comparison between the generic disaster model described by Travalgia et al. with Turner's work, both in terms of his stage model and focus on causality across system levels would be a worthwhile future undertaking and might help us go further towards learning from patient safety disasters.

Competing interests None.

References

(1) Travaglia JF, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors. BMJQS 2011; 20:1-8.

(2) Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding lights? Learning from disasters to improve patient safety. Qual Saf Health Care 2010;19: 332-336

(3) Weick KE, Sutcliffe KM, Hospitals as cultures of re-enactment: a re-analysis of the Bristol Royal Infirmary. California Management Review, 2003; 45:2, 73-84.

(4) Turner BA, Man-made Disasters. London: Wykeham Publications, 1978.

(5) Turner, BA, Pidgeon NF, Man-made Disasters (Second Edition) Oxford: Butterworth-Heinemann, 1997.

(6) Pidgeon NF, O'Leary M. Man-made disasters: why technology and organizations (sometimes) fail. Safety Science 2000; 34:15-30.

Conflict of Interest:

None declared