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Error management
Bad stars or guiding lights? Learning from disasters to improve patient safety
  1. C Hughes1,
  2. J F Travaglia2,
  3. J Braithwaite2
  1. 1Clinical Excellence Commission, Sydney, New South Wales, Australia
  2. 2Centre for Clinical Governance Research in Health, Institute of Health Innovation, Faculty of Medicine , University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Joanne F Travaglia, Centre for Clinical Governance Research in Health, Institute of Health Innovation, Faculty of Medicine, University of New South Wales, 10 Arthur Street, Randwick, NSW 2052, Australia

Abstract

Background Cross-fertilisation of ideas across industries, settings and contexts potentially improves learning by providing fresh insights into error pathways.

Objectives and hypotheses To investigate six cases of human error drawn from disasters in the space, shipping, aviation, mining, rail and nuclear industries, and to apprehend similarities and differences in the antecedents to errors, the way they manifest, the course of events and the way they are tackled. The extent to which human intervention can exacerbate the problems by introducing new errors, how the cases are resolved and the lessons learnt were examined.

Design, setting and participants Exemplar disaster events drawn from a very large sample of human errors.

Results It is possible to identify and model a generic disaster pathway that applies across several industries, including healthcare.

Conclusions Despite differences between industries, it is clear that learning from disasters in other industries may provide important insights on how to prevent or ameliorate them in healthcare.

  • safety
  • root cause analysis
  • human error
  • health system
  • disasters
  • safety culture
  • health care quality

https://doi.org/10.1136/qshc.2008.030148

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    Footnotes

    • Funding Is provided in part by National Health and Medical Research Council Program Grant 568612 and by the Australian Research Council's Linkage Project funding scheme (project number LP0775514).

    • Competing Interest None.

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