Human Error in Medicine

By Marilyn Sue Bogner | Go to book overview

Foreword

James T. Reason University of Manchester

This last decade or so has seen a growing openness on the part of the medical profession regarding the part played by human error in mishaps to patients. The pursuit of safety is a multidisciplinary enterprise, and this is as true for patient safety, hitherto an exclusively medical domain, as for any other kind. This new spirit of glasnost has led to an increasing number of fruitful research partnerships between doctors (particularly anesthetists) and human factors specialists. One of the most important results of these collaborations has been the awareness that medical accidents share many important causal similarities with the breakdown of other complex sociotechnical systems, such as the Chernobyl Unit 4 reactor. Some idea of what factors are involved in these accidents is provided by the sad story of Valeri Legasov, the chief Soviet investigator of the Chernobyl accident.


FRONTLINE ERRORS ARE NOT THE WHOLE TRUTH

In August 1986, 4 months after the world's worst nuclear accident at Chernobyl, a Soviet team of investigators, headed by academician Valeri Legasov, presented their findings to a meeting of nuclear experts, convened in Vienna by the International Atomic Energy Agency. In a verbal report lasting 5 hours, Legasov described both the sequence of events leading up to the accident and the heroic attempts to contain its aftermath. In his address, Legasov put the blame for the disaster squarely on the errors and especially the procedural violations committed by the plant operators. The report was

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