Is technical perfection enough?

He points out that humans make frequent errors, in predictable and patterned ways, and discusses how these risks can be minimized

Professor James Reason is Professor Emeritus of Psychology at Manchester University and is widely recognised as the world leading expert on human error. In his forward to the excellent book called Patient Safety in Emergency Medicine,1 he explains that there is a paradox at the heart of the patient safety problem. Medical education, almost uniquely, is predicated on an assumption of trained perfectibility. After a long, arduous and expensive education, doctors are expected to get it right. But they are fallible human beings like the rest of us. For many of them error equates to incompetence, or worse. Mistakes are stigmatised, rather than seen as chances for learning. The other part of the paradox is that healthcare, by its very nature, is highly error provoking. Many other high risk industries have learnt that trained perfectibility does not guarantee a safe culture. Aviation accidents, by their very nature, receive instant press attention with pictures of charred hulls featuring on newspaper front covers and TV news channels within minutes of the incident’s occurrence. It was such images that ignited aviation regulators’ attention some 30 or 40 years ago. Accidents were being tagged as being aviation style, into the medical or surgical setting. It would, however, seem sensible to use some of the principles to simplify the arduous path that aviation has followed in this regard. My colleague, Trevor Dale, and I were fortunate to be two key members of the small team that developed and introduced human factors training into British Airways. The model that we helped create is now the standard for aviation human factors training within Europe. In 2001, we were invited to join a research programme at Great Ormond Street Hospital.2 On completion of that research programme, we founded our human factors consultancy, Atrainability.3 We have now retired from British Airways and are now working full time within healthcare training and coaching multidisciplinary teams in various healthcare specialties.

Improving the safety of surgical patients