Aviation & Medicine & Culture
Some excerpts from Problems and Perils of Prescription Medicines
<http://www.blacktriangle.org/reason.html>
Aviation [safety] is predicated on the assumption that people screw-up. You (healthcare professionals) on the other hand are extensively educated to get it right and so you don’t have a culture where you share readily the notion of error.
Errors can’t be eliminated but they can be managed.
Error is extremely adaptive
Error is not random, it is not out of the blue, and it is largely predictable.... It is very contextual.
Find error traps -- to do that you need a database, some kind of error collecting system. You need a reporting system; you need a near miss reporting system. You need a memory. Without that you have no idea of identifying where these errors occur.
The other much more manageable area are latent conditions I used to call them latent errors, but they are just latent conditions... they are always there.... So just like mosquitoes you swat one and another appears, so the only way of dealing with the error problem is to go to the latent condition, to go to the systemic swamps in which they breed
Then there is the obvious thing about naming blaming and shaming,
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