Bad stars or guiding lights? Learning from disasters to improve patient safety.
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.


METHODS
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.
Hughes
C
C
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.
Travaglia
J F
JF
Braithwaite
J
J
D003695:Delivery of Health Care / Q000592:standards*; D004189:Disaster Planning; D004190:Disasters; D004638:Emergency Treatment; D006801:Humans; D007221:Industry; D007858:Learning; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety / Q000592:standards*