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  1. T B Sheridan
  1. 32 Sewall Street, Newton, MA 02465, USA;

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    In the 1970s and 1980s there was great interest among applied psychologists and systems reliability engineers in analysing accidents and “near miss” incidents in large scale systems where public safety was a primary concern. Efforts to define and develop taxonomies of human error were motivated by the meltdown at the Three Mile Island power plant near Harrisbug, PA, by the nuclear plant accident at Chernobyl in the Soviet Union, by the poison gas release at Bhopal, India, and by aviation’s most deadly crash of two 747 aircraft at Tenerife in the Canary Islands. Key to these efforts were the contributions of Professor Jens Rasmussen of the Riso Energy Laboratory and the University of Copenhagen in Denmark.1–3 Riso had been assigned the task of evaluating whether Denmark should build nuclear plants (it was eventually decided not to, although neighbours Sweden and Germany had made the decision to go ahead with nuclear power). Human error rather suddenly became a fashionable topic in the human factors or “cognitive engineering” field, and an early series of international meetings was convened by John Senders4 of University of Toronto. Subsequently, James Reason5 of Manchester University in the UK and Erik Hollnagel6 of Linkoping University in Denmark wrote well known books on human error. All the while the US medical community, while not ignoring patient safety, seemed reluctant to participate actively in such discussions of human error, the medical culture being oriented to avoiding public scrutiny of medical error for obvious reasons of exposure to litigation. Only in the last two decades has the medical community become open to taking a hard look at medical error. The anesthesiology patient safety movement led by Dr David Gaba of Stanford VA Hospital was one early push in this direction, and there were other patient …

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