TY - JOUR
T1 - Republished paper
T2 - Bad stars or guiding lights? Learning from disasters to improve patient safety
AU - Hughes, C.
AU - Travaglia, Joanne F.
AU - Braithwaite, J.
PY - 2010/11
Y1 - 2010/11
N2 - 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.
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.
UR - http://www.scopus.com/inward/record.url?scp=78149319868&partnerID=8YFLogxK
UR - http://purl.org/au-research/grants/nhmrc/568612
U2 - 10.1136/pgmj.2008.030148rep
DO - 10.1136/pgmj.2008.030148rep
M3 - Review article
C2 - 21037239
AN - SCOPUS:78149319868
SN - 0032-5473
VL - 86
SP - 675
EP - 679
JO - Postgraduate Medical Journal
JF - Postgraduate Medical Journal
IS - 1021
ER -