Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors.

摘要

In a previous paper we developed a generic disaster pathway model drawing from disaster inquiries in the space, shipping, aviation, mining, rail and nuclear industries. To test our hypothesis that our generic disaster model can be applied to healthcare errors, we ustilised three exemplar cases featuring different types and sources of errors. We found that it is possible to apply our generic disaster pathway to healthcare errors, and to identify the combination of human, organisational and design risk factors which contribute to the severity and speed at which errors occur. We conclude that error pathways provide a useful tool from which healthcare services can learn to appreciate and potentially circumvent or ameliorate errors, prior to their reaching the no-return threshold.