RT Journal Article
SR Electronic
T1 Bad stars or guiding lights? Learning from disasters to improve patient safety
JF Quality and Safety in Health Care
JO Qual Saf Health Care
FD BMJ Publishing Group Ltd
SP 332
OP 336
DO 10.1136/qshc.2008.030148
VO 19
IS 4
A1 C Hughes
A1 J F Travaglia
A1 J Braithwaite
YR 2010
UL http://qualitysafety.bmj.com/content/19/4/332.abstract
AB 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.