Lessons learned from non-medical industries: the tragedy of the USS Greeneville.
In February 200l the nuclear powered submarine USS Greeneville collided with the Japanese fishing trawler Ehime Maru, killing nine passengers. A series of small failures and hurried actions escalated into tragedy. This incident provides lessons learned that can be used by healthcare organizations to improve patient safety. Expertise, training, equipment, and procedures appeared to be adequate protection, yet the presence of multiple defences obscured their faulty functioning, just as they often do in medical settings. A number of other problems occurred aboard Greeneville which we also see in health care. The problem was the total breakdown of communication. The Greeneville team also failed to move from a rigid hierarchical structure to a more flexible adaptive structure. Communication often breaks down in healthcare settings, which are organized to maximize status and hierarchical differences, thus often impeding information flow needed to make decisions. Redundancy failed aboard Greeneville as it often does in medicine. Finally, the Captain of the Greeneville established an artificially hurried situation. Time constrained situations happen all the time in health care. We recommend strategies to mitigate the development of these kinds of processes.
Roberts
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KH
University of California, Berkeley, CA, USA. karlene@haas.berkeley.edu
Tadmor
C T
CT
D000062:Accidents, Occupational / Q000401:mortality*; D001519:Behavior; D003142:Communication; D006804:Ergonomics; D005398:Fisheries; D006254:Hawaii; D006801:Humans; D019300:Medical Errors; D008889:Military Personnel / Q000523:psychology*; D008891:Military Science / Q000379:methods / Q000592:standards*; D010140:Pacific Ocean; D012308:Risk Management; D012767:Ships / Q000592:standards*; D013597:Systems Analysis; D013995:Time; D014481:United States